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What Is Therapy Homework?

Sanjana is a health writer and editor. Her work spans various health-related topics, including mental health, fitness, nutrition, and wellness.

Dr. Sabrina Romanoff, PsyD, is a licensed clinical psychologist and a professor at Yeshiva University’s clinical psychology doctoral program.

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Types of Therapy That Involve Homework

If you’ve recently started going to therapy , you may find yourself being assigned therapy homework. You may wonder what exactly it entails and what purpose it serves. Therapy homework comprises tasks or assignments that your therapist asks you to complete between sessions, says Nicole Erkfitz , DSW, LCSW, a licensed clinical social worker and executive director at AMFM Healthcare, Virginia.

Homework can be given in any form of therapy, and it may come as a worksheet, a task to complete, or a thought/piece of knowledge you are requested to keep with you throughout the week, Dr. Erkfitz explains.

This article explores the role of homework in certain forms of therapy, the benefits therapy homework can offer, and some tips to help you comply with your homework assignments.

Therapy homework can be assigned as part of any type of therapy. However, some therapists and forms of therapy may utilize it more than others.

For instance, a 2019-study notes that therapy homework is an integral part of cognitive-behavioral therapy (CBT) . According to Dr. Erkfitz, therapy homework is built into the protocol and framework of CBT, as well as dialectical behavior therapy (DBT) , which is a sub-type of CBT.

Therefore, if you’re seeing a therapist who practices CBT or DBT, chances are you’ll regularly have homework to do.

On the other hand, an example of a type of therapy that doesn’t generally involve homework is eye movement desensitization and reprocessing (EMDR) therapy. EMDR is a type of therapy that generally relies on the relationship between the therapist and client during sessions and is a modality that specifically doesn’t rely on homework, says Dr. Erkfitz.

However, she explains that if the client is feeling rejuvenated and well after their processing session, for instance, their therapist may ask them to write down a list of times that their positive cognition came up for them over the next week.

"Regardless of the type of therapy, the best kind of homework is when you don’t even realize you were assigned homework," says Erkfitz.

Benefits of Therapy Homework

Below, Dr. Erkfitz explains the benefits of therapy homework.

It Helps Your Therapist Review Your Progress

The most important part of therapy homework is the follow-up discussion at the next session. The time you spend reviewing with your therapist how the past week went, if you completed your homework, or if you didn’t and why, gives your therapist valuable feedback on your progress and insight on how they can better support you.

It Gives Your Therapist More Insight

Therapy can be tricky because by the time you are committed to showing up and putting in the work, you are already bringing a better and stronger version of yourself than what you have been experiencing in your day-to-day life that led you to seek therapy.

Homework gives your therapist an inside look into your day-to-day life, which can sometimes be hard to recap in a session. Certain homework assignments keep you thinking throughout the week about what you want to share during your sessions, giving your therapist historical data to review and address.

It Helps Empower You

The sense of empowerment you can gain from utilizing your new skills, setting new boundaries , and redirecting your own cognitive distortions is something a therapist can’t give you in the therapy session. This is something you give yourself. Therapy homework is how you come to the realization that you got this and that you can do it.

"The main benefit of therapy homework is that it builds your skills as well as the understanding that you can do this on your own," says Erkfitz.

Tips for Your Therapy Homework

Below, Dr. Erkfitz shares some tips that can help with therapy homework:

Set aside time for your homework: Create a designated time to complete your therapy homework. The aim of therapy homework is to keep you thinking and working on your goals between sessions. Use your designated time as a sacred space to invest in yourself and pour your thoughts and emotions into your homework, just as you would in a therapy session .
Be honest: As therapists, we are not looking for you to write down what you think we want to read or what you think you should write down. It’s important to be honest with us, and yourself, about what you are truly feeling and thinking.
Practice your skills: Completing the worksheet or log are important, but you also have to be willing to put your skills and learnings into practice. Allow yourself to be vulnerable and open to trying new things so that you can report back to your therapist about whether what you’re trying is working for you or not.
Remember that it’s intended to help you: Therapy homework helps you maximize the benefits of therapy and get the most value out of the process. A 2013-study notes that better homework compliance is linked to better treatment outcomes.
Talk to your therapist if you’re struggling: Therapy homework shouldn’t feel like work. If you find that you’re doing homework as a monotonous task, talk to your therapist and let them know that your heart isn’t in it and that you’re not finding it beneficial. They can explain the importance of the tasks to you, tailor your assignments to your preferences, or change their course of treatment if need be.

"When the therapy homework starts 'hitting home' for you, that’s when you know you’re on the right track and doing the work you need to be doing," says Erkfitz.

A Word From Verywell

Similar to how school involves classwork and homework, therapy can also involve in-person sessions and homework assignments.

If your therapist has assigned you homework, try to make time to do it. Completing it honestly can help you and your therapist gain insights into your emotional processes and overall progress. Most importantly, it can help you develop coping skills and practice them, which can boost your confidence, empower you, and make your therapeutic process more effective.

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Conklin LR, Strunk DR, Cooper AA. Therapist behaviors as predictors of immediate homework engagement in cognitive therapy for depression . Cognit Ther Res . 2018;42(1):16-23. doi:10.1007/s10608-017-9873-6

Lebeau RT, Davies CD, Culver NC, Craske MG. Homework compliance counts in cognitive-behavioral therapy . Cogn Behav Ther . 2013;42(3):171-179. doi:10.1080/16506073.2013.763286

By Sanjana Gupta Sanjana is a health writer and editor. Her work spans various health-related topics, including mental health, fitness, nutrition, and wellness.

Sending Homework to Clients in Therapy: The Easy Way

Successful therapy relies on using assignments outside of sessions to reinforce learning and practice newly acquired skills in real-world settings (Mausbach et al., 2010).

Up to 50% of clients don’t adhere to homework compliance, often leading to failure in CBT and other therapies (Tang & Kreindler, 2017).

In this article, we explore how to use technology to create homework, send it out, and track its completion to ensure compliance.

Before you continue, we thought you might like to download our three Positive Psychology Exercises for free . These science-based exercises will explore fundamental aspects of positive psychology including strengths, values, and self-compassion, and will give you the tools to enhance the wellbeing of your clients, students, or employees.

This Article Contains:

Is homework in therapy important, how to send homework to clients easily, homework in quenza: 5 examples of assignments, 5 counseling homework ideas and worksheets, using care pathways & quenza’s pathway builder, a take-home message.

Cognitive-Behavioral Therapy has “been shown to be as effective as medications in the treatment of a number of psychiatric illnesses” (Tang & Kreindler, 2017, p. 1).

Homework is a vital component of CBT, typically involving completing a structured and focused activity between sessions.

Practicing what was learned in therapy helps clients deal with specific symptoms and learn how to generalize them in real-life settings (Mausbach et al., 2010).

CBT practitioners use homework to help their clients, and it might include symptom logs, self-reflective journals , and specific tools for working on obsessions and compulsions. Such tasks, performed outside therapy sessions, can be divided into three types (Tang & Kreindler, 2017):

Psychoeducation Reading materials are incredibly important early on in therapy to educate clients regarding their symptoms, possible causes, and potential treatments.
Self-assessment Monitoring their moods and completing thought records can help clients recognize associations between their feelings, thoughts, and behaviors.
Modality specific Therapists may assign homework that is specific and appropriate to the problem the client is presenting. For example, a practitioner may use images of spiders for someone with arachnophobia.

Therapists strategically create homework to lessen patients’ psychopathology and encourage clients to practice skills learned during therapy sessions, but non-adherence (between 20% and 50%) remains one of the most cited reasons for CBT failure (Tang & Kreindler, 2017).

Reasons why clients might fail to complete homework include (Tang & Kreindler, 2017):

Internal factors

Lack of motivation to change what is happening when experiencing negative feelings
Being unable to identify automatic thoughts
Failing to see the importance or relevance of homework
Impatience and the wish to see immediate results

External factors

Effort required to complete pen-and-paper exercises
Inconvenience and amount of time to complete
Failing to understand the purpose of the homework, possibly due to lack of or weak instruction
Difficulties encountered during completion

Homework compliance is associated with short-term and long-term improvement of many disorders and unhealthy behaviors, including anxiety, depression, pathological behaviors, smoking, and drug dependence (Tang & Kreindler, 2017).

Greater homework adherence increases the likelihood of beneficial therapy outcomes (Mausbach et al., 2010).

With that in mind, therapy must find ways to encourage the completion of tasks set for the client. Technology may provide the answer.

The increased availability of internet-connected devices, improved software, and widespread internet access enable portable, practical tools to enhance homework compliance (Tang & Kreindler, 2017).

Clients who complete their homework assignments progress better than those who don’t (Beck, 2011).

Having an ideal platform for therapy makes it easy to send and track clients’ progress through assignments. It must be “user-friendly, accessible, reliable and secure from the perspective of both coach and client” (Ribbers & Waringa, 2015, p. 103).

In dedicated online therapy and coaching software, homework management is straightforward. The therapist creates the homework then forwards it to the client. They receive a notification and complete the work when it suits them. All this is achieved in one system, asynchronously; neither party needs to be online at the same time.

For example, in Quenza , the therapist can create a worksheet or tailor an existing one from the library as an activity that asks the client to reflect on the progress they have made or work they have completed.

The activity can either be given directly to the client or group, or included in a pathway containing other activities.

Here is an example of the activity parameters that Quenza makes possible.

A message can be attached to the activity, using either a template or a personally tailored message for the client. Here’s an example.

Once the activity is published and sent, the client receives a notification about a received assignment via their coaching app (mobile or desktop) or email.

The client can then open the Quenza software and find the new homework under their ‘To Do’ list.

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Quenza provides the ability to create your own assignments as well as a wide selection of existing ones that can be assigned to clients for completion as homework.

The following activities can be tailored to meet specific needs or used as-is. Therapists can share them with the client individually or packaged into dedicated pathways.

Such flexibility allows therapists to meet the specific needs of the client using a series of dedicated and trackable homework.

Examples of Quenza’s ready-to-use science-based activities include the following:

Wheel of Life

The Wheel of Life is a valuable tool for identifying and reflecting on a client’s satisfaction with life.

You can find the worksheet in the Positive Psychology Toolkit© , and it is also included in the Quenza library. The client scores themselves between 1 and 10 on specific life domains (the therapist can tailor the domains), including relationships, career development, and leisure time.

This is an active exercise to engage the client early on in therapy to reflect on their current and potential life. What is it like now? How could it look?

The wheel identifies where there are differences between perceived balance and reality .

The deep insights it provides can provide valuable input and prioritization for goal setting.

The Private Garden: A Visualization for Stress Reduction

While stress is a normal part of life, it can become debilitating and interfere with our everyday lives, stopping us from reaching our life goals.

We may notice stress as worry, anxiety, and tension and resort to avoidant or harmful behaviors (e.g., abusing alcohol, smoking, comfort eating) to manage these feelings.

Visualization is simple but a powerful method for reducing physical and mental stress, especially when accompanied by breathing exercises.

The audio included within this assignment helps the listener visualize a place of safety and peace and provides a temporary respite from stressful situations.

20 Guidelines for Developing a Growth Mindset

Research into neuroplasticity has confirmed the ability of the adult brain to continue to change in adulthood and the corresponding capacity for people to develop and transform their mindsets (Dweck, 2017).

The 20 guidelines (included in our Toolkit and part of the Quenza library) and accompanying video explain our ability to change mentally and develop a growth mindset that includes accepting imperfection, leaning into challenges, continuing to learn, and seeing ‘failure’ as an opportunity for growth.

Adopting a growth mindset can help clients understand that our abilities and understanding are not fixed; we can develop them in ways we want with time and effort.

Self-Contract

Committing to change is accepted as an effective way to promote behavioral change – in health and beyond. When a client makes a contract with themselves, they explicitly state their intention to deliver on plans and short- and long-term goals.

Completing and signing such a self-contract (included in our Toolkit and part of the Quenza library) online can help people act on their commitment through recognizing and living by their values.

Not only that, the contract between the client and themselves can be motivational, building momentum and self-efficacy.

The contract can be automatically personalized to include the client’s name but also manually reworded as appropriate.

The client completes the form by restating their name and committing to a defined goal by a particular date, along with their reasons for doing so.

Realizing Long-Lasting Change by Setting Process Goals

We can help clients realize their goals by building supportive habits. Process goals – for example, eating healthily and exercising – require ongoing actions to be performed regularly.

Process goals (unlike end-state goals, such as saving up for a vacation) require long-lasting and continuous change that involves monitoring standards.

This tool (included in our Toolkit and part of the Quenza library) can help clients identify positive actions (rather than things to avoid) that they must carry out repeatedly to realize change.

We have many activities that can be used to help clients attending therapy for a wide variety of issues.

In this section, we consider homework ideas that can be used in couples therapy, family therapy, and supporting clients with depression and anxiety.

Couples therapy homework

Conflict is inevitable in most long-term relationships. Everyone has their idiosyncrasies and individual set of needs. The Marital Conflicts worksheet captures a list of situations in which conflicts arise, when they happen, and how clients feel when they are (un)resolved.

Family therapy homework

Families, like individuals, are susceptible to times of stress and disruptions because of life changes such as illness, caring for others, and job and financial insecurity.

Mind the Gap is a family therapy worksheet where a family makes decisions together to align with goals they aspire to. Mind the gap is a short exercise to align with values and improve engagement.

How holistic therapist Jelisa Glanton uses Quenza

Homework ideas for depression and anxiety: 3 Exercises

The following exercises are all valuable for helping clients with the effects of anxiety and depression.

Activity Schedule is a template assisting a client with scheduling and managing normal daily activities, especially important for those battling with depression.

Activity Menu is a related worksheet, allowing someone with depression to select from a range of normal activities and ideas, and add these to a schedule as goals for improvement.

The Pleasurable Activity Journal focus on activities the client used to find enjoyable. Feelings regarding these activities are journaled, to track recovery progress.

Practicing mindfulness is helpful for those experiencing depression (Shapiro, 2020). A regular gratitude practice can develop new neural pathways and create a more grateful, mindful disposition (Shapiro, 2020).

Each activity can be tailored to the client’s needs; shared as standalone exercises, worksheets, or questionnaires; or included within a care pathway.

A pathway is an automated and scheduled series of activities that can take the client through several stages of growth, including psychoeducation , assessment, and action to produce a behavioral change in a single journey.

How to build pathways

The creator can add two pathway titles. The second title is not necessary, but if entered, it is seen by the client in place of the first.

Once named, a series of steps can be created and reordered at any time, each containing an activity. Activities can be built from scratch, modified from existing ones in the library, or inserted as-is.

New activities can be created and used solely in this pathway or made available for others. They can contain various features, including long- and short-answer boxes, text boxes, multiple choice boxes, pictures, diagrams, and audio and video files.

Quenza can automatically deliver each step or activity in the pathway to the client following the previous one or after a certain number of days. Such timing is beneficial when the client needs to reflect on something before completing the next step.

Practitioners can also designate steps as required or optional before the client continues to the next one.

Practitioners can also add helpful notes not visible to the client. These comments can contain practical reminders of future changes or references to associated literature that the client does not need to see.

It is also possible to choose who can see client responses: the client and you, the client only, or the client decides.

Tags help categorize the pathway (e.g., by function, intended audience, or suggested timing within therapy) and can be used to filter what is displayed on the therapist’s pathway screen.

Once designed, the pathway can be saved as a draft or published and sent to the client. The client receives the notification of the new assignment either via email or the coaching app on their phone, tablet, or desktop.

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Success in therapy is heavily reliant on homework completion. The greater the compliance, the more likely the client is to have a better treatment outcome (Mausbach et al., 2010).

To improve the likelihood that clients engage with and complete the assignments provided, homework must be appropriate to their needs, have a sound rationale, and do the job intended (Beck, 2011).

Technology such as Quenza can make homework readily available on any device, anytime, from any location, and ensure it contains clear and concise psychoeducation and instructions for completion.

The therapist can easily create, copy, and tailor homework and, if necessary, combine multiple activities into single pathways. These are then shared with the click of a button. The client is immediately notified but can complete it at a time appropriate to them.

Quenza can also send automatic reminders about incomplete assignments to the client and highlight their status to the therapist. Not only that, but any resulting questions can be delivered securely to the therapist with no risk of getting lost in a busy email inbox.

Why not try the Quenza application? Try using some of the existing science-based activities or create your own. It offers an impressive array of functionality that will not only help you scale your business, but also ensure proactive, regular communication with your existing clients.

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

Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond . Guilford Press.
Dweck, C. S. (2017). Mindset: The new psychology of success. Robinson.
Mausbach, B. T., Moore, R., Roesch, S., Cardenas, V., & Patterson, T. L. (2010). The relationship between homework compliance and therapy outcomes: An updated meta-analysis. Cognitive Therapy and Research , 34 (5), 429–438.
Ribbers, A., & Waringa, A. (2015). E-coaching: Theory and practice for a new online approach to coaching . Routledge.
Shapiro, S. L. (2020). Rewire your mind: Discover the science and practice of mindfulness. Aster.
Tang, W., & Kreindler, D. (2017). Supporting homework compliance in cognitive behavioural therapy: Essential features of mobile apps. JMIR Mental Health , 4 (2).

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How Much Does Homework Matter in Therapy?

What research reveals about the work you do outside of therapy sessions..

Posted April 16, 2017 | Reviewed by Ekua Hagan

What Is Therapy?
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Homework is an important component of cognitive behavior therapy (CBT) and other evidence-based treatments for psychological symptoms. Developed collaboratively during therapy sessions, homework assignments may be used by clients to rehearse new skills, practice coping strategies, and restructure destructive beliefs.

Although some clients believe that the effectiveness of psychotherapy depends on the quality of in-session work, consistent homework during the rest of the week may be even more important. Without homework, the insights, plans, and good intentions that emerge during a therapy session are at risk of being buried by patterns of negative thinking and behavior that have been strengthened through years of inadvertent rehearsal. Is an hour (or less) of therapeutic work enough to create change during the other 167 hours in a week?

Research on homework in therapy

Research on homework in therapy has revealed some meaningful results that can be understood collectively through a procedure called meta-analysis. A meta-analysis is a statistical summary of a body of research. It can be used to identify the average impact of psychotherapy homework on treatment outcomes across numerous studies. The results of four meta-analyses listed below highlight the value of homework in therapy:

Kazantzis and colleagues (2010) examined 14 controlled studies that directly compared treatment outcomes for clients assigned to psychotherapy with or without homework. The data favored the homework conditions, with the average client in the homework group reporting better outcomes than about 70% of those in the no-homework conditions.
Results from 16 studies (Kazantzis et al., 2000) and an updated analysis of 23 studies (Mausbach et al., 2010) found that, among those who received homework assignments during therapy, greater compliance led to better treatment outcomes. The effect sizes were small to medium, depending on the method used to measure compliance.
Kazantzis et al. (2016) examined the relations of both quantity (15 studies) and quality (3 studies) of homework to treatment outcome. The effect sizes were medium to large, and these effects remained relatively stable when follow-up data were collected 1-12 months later.

Taken together, the research suggests that the addition of homework to psychotherapy enhances its effectiveness and that clients who consistently complete homework assignments tend to have better mental health outcomes. Finally, although there is less research on this issue, the quality of homework may matter as much as the amount of homework completed.

To enhance the quality of homework, homework assignments should relate directly to a specific goal, the process should be explained with clarity by the therapist, its method should be rehearsed in session, and opportunities for thoughtful out-of-session practice should be scheduled with ideas about how to eliminate obstacles to completion.

To find a therapist, please visit the Psychology Today Therapy Directory .

Kazantzis, N., Deane, F. P., & Ronan, K. R. (2000). Homework assignments in Cognitive and Behavioral Therapy: A meta‐analysis. Clinical Psychology: Science and Practice, 7(2), 189-202.

Kazantzis, N., Whittington, C., & Dattilio, F. (2010). Meta‐analysis of homework effects in cognitive and behavioral therapy: A replication and extension. Clinical Psychology: Science and Practice, 17(2), 144-156.

Kazantzis, N., Whittington, C., Zelencich, L., Kyrios, M., Norton, P. J., & Hofmann, S. G. (2016). Quantity and quality of homework compliance: a meta-analysis of relations with outcome in cognitive behavior therapy. Behavior Therapy, 47(5), 755-772.

Mausbach, B. T., Moore, R., Roesch, S., Cardenas, V., & Patterson, T. L. (2010). The relationship between homework compliance and therapy outcomes: An updated meta-analysis. Cognitive Therapy and Research, 34(5), 429-438.

Joel Minden, Ph.D., is a clinical psychologist, author of Show Your Anxiety Who’s Boss , director of the Chico Center for Cognitive Behavior Therapy, and lecturer in the Department of Psychology at California State University, Chico.

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Homework in Cognitive Behavioral Supervision: Theoretical Background and Clinical Application

1 Department of Psychiatry, University Hospital Olomouc, Faculty of Medicine, Palacky University in Olomouc, Olomouc, The Czech Republic

2 Department of Psychology Sciences, Faculty of Social Science and Health Care, Constantine the Philosopher University in Nitra, Nitra, The Slovak Republic

3 Department of Psychotherapy, Institute for Postgraduate Training in Health Care, Prague, The Czech Republic

4 Jessenia Inc. - Rehabilitation Hospital Beroun, Akeso Holding, Beroun, The Czech Republic

Ilona Krone

5 Riga`s Stradins University, Riga, Latvia

Julius Burkauskas

6 Laboratory of Behavioral Medicine, Neuroscience Institute, Lithuanian University of Health Sciences, Kaunas, Lithuania

Jakub Vanek

Marija abeltina.

7 University of Latvia, Latvian Association of CBT, Riga, Latvia

Alicja Juskiene

Tomas sollar, milos slepecky, marie ociskova.

The homework aims to generalize the patient’s knowledge and encourage practicing skills learned during therapy sessions. Encouraging and facilitating homework is an important part of supervisees in their supervision, and problems with using homework in therapy are a common supervision agenda. Supervisees are encouraged to conceptualize the patient’s lack of homework and promote awareness of their own beliefs and responses to non-cooperation. The supervision focuses on homework twice – first as a part of the supervised therapy and second as a part of the supervision itself. Homework assigned in supervision usually deals with mapping problems, monitoring certain behaviors (mostly communication with the patient), or implementing new behaviors in therapy.

Introduction

The development of competent clinical supervision is crucial to effectively training new CBT therapists and supervisors and maintaining high therapy standards throughout their careers. 1 Clinical supervision is a basis for CBT training, but there are only a few empirical evaluations on the effect of supervision on therapists’ competencies. Wilson et al 2 in their systematic review and meta-analysis, synthesized the experience and impact of supervision for trainee therapists from 15 qualitative studies. Although supervision leads to feelings of distress and self-doubts, it can effectively support supervisees in personal and professional development. It could similarly harm supervisees’ well-being, clinical work and clients’ experiences. Alfonsson et al 3 published a study to evaluate the effects of standardized supervision on rater-assessed competency in six CBT therapists under protocol-based clinical supervision. This is one of the first investigations showing that supervision affects cognitive behavioral competencies. Although several works have studied the effectiveness of supervision on the therapist’s competence and for the therapist’s work with patients in qualitative studies, 3–7 there is still a lack of studies that dealt with the importance of homework in supervision.

Homework is a vital element of cognitive behavioral therapy (CBT) which distinguishes it from many other psychotherapeutic approaches. 8–10 Patients usually participate in therapy by completing homework assignments and taking responsibility for their course.

Assigning and discussing homework is one of the basic competencies of a cognitive-behavioral therapist and a supervisor in the context of counselling, psychology, therapy, and social work. The manuscript aims to refer to homework in several settings: homework in therapy, supervision of homework in therapy, using the homework by the supervisor for the supervisee, and homework in the training of supervisors.

Homework in Therapy

While specific recommendations for the practical usage of homework have been clearly articulated since the early days of CBT, 11 , 12 practitioners state that they do not follow these recommendations. 13–15 For example, many physicians admit that they forget homework or do not focus on standard specifications when, where, how often, and how long the task should last. Often reported non-cooperation in homework assignments may be due to the practice recommendations being too strict or because students think the amount of homework they can assign is limited. 16

The Sense of Homework in the Therapy

Patients verify methods and skills they learned during the session in real situations and the natural environment. 9 , 17 Through homework, patients also test hypotheses that emerged during the session with the therapist (for example, “If I went out on the street alone, I would be so weak that I would pass out or lose control completely”). Homework help that the important part of the therapy takes place between sessions and allows the patients to become independent and manage their problems even after the end of therapy. 10 , 18 Patients learn how to raise hypotheses and test them in real-life situations. Through completing homework persistently during the therapy, patients gain skills on how to plan their activities and gain new skills, and they also collect a rich source of therapeutic diaries. The investigations advocate that adding homework to CBT increases its efficacy and that patients who constantly complete homework have better outcomes. The outcomes of four meta-analyses highlight the value of homework in CBT:

Kazantzis et al 10 inspected 14 studies that compared results for patients allocated to CBT without or with homework. The average patient in the homework group reported better results than about 70% of controls.
Outcomes from 16 studies 17 and an updated analysis of 23 studies 19 discovered that higher compliance led to better treatment results among patients who received homework projects during therapy.
Kazantzis et al 20 studied the relationships between quantity (15 studies) and quality (3 studies) of the homework to treatment results. The effect sizes were medium to large, and these effects remained fairly constant in a 12-month follow-up.

Therapists strategically create homework to reduce patients’ psychopathology and encourage them to practice skills learned during therapy sessions; nevertheless, non-adherence (between 20% and 50%) remains one of the most cited reasons for decreased CBT efficacy. 21 Several reasons for non-adherence to homework might be pointed out –the therapist does not regularly discuss homework with the patient, the patient no longer considers it important and stop doing it. 9 , 22 Discussing homework also allows the therapist to strengthen the patient’s belief in their ability to achieve certain goals. 23 The fact that the patient has completed the assignment must be properly acknowledged, and then therapists discuss the quality of homework separately. 24 Good questions might be, “How did you do your homework? Were there any difficulties in fulfilling them? What kind?” Furthermore: “How can you handle these problems next time? What did you learn while completing your homework? Can it help you cope with other issues?”

How to Increase the Effectiveness of Homework in the Therapy

Homework is the most effective, and it is most likely to succeed if: 19 , 25

Follows logically from the topics discussed during the session and uses the methods that the patient learned during the session;
they are clearly and concretely defined, so it is easy to determine whether or to what extent the patient has been successful in fulfilling them (eg, “Leaving the house alone for at least 30 minutes every day”, not “Starting to go out alone”);
the patient clearly understands their meaning (“To verify your belief that you will faint on the street” or “See for yourself whether your anxiety will continue to rise, remain the same or subside after a certain time”), and they believe they can achieve the goals;
homework is formulated so that failure is impossible because, in any case, the patient will learn something useful that will help them in therapy;
the therapist anticipates and discusses obstacles that could hinder the fulfilment of homework and plans procedures to overcome them.

An important aspect of CBT is the patient’s independence. 10 , 18 Homework is typically determined by consensus. To increase the likelihood that the patient will complete the homework, the patient and the therapist should document their assignments in writing. Additionally, it is very convenient for the patient to record the homework, typically pre-prepared. 24 These records serve as a basis for discussing homework in the next session and also allow the therapist to assess the changes achieved during therapy (“A month ago, you were able to go out alone for only half an hour and your anxiety level previously reached level ‘9’, while now you were alone outside for more than an hour and your anxiety do not exceed ‘5’ rated subjectively”).

Because the goal of therapy is to help the patient experience success, the patient’s assigned homework must be feasible. 18 , 26 On the other hand, patients should improve their ability to cope with problems and unpleasant conditions during therapy, they need to exert significant effort to overcome certain unpleasant feelings and emotions. 19 , 20

Even if therapists follow all these rules, they will unavoidably find that sometimes the patient does not complete assigned homework. 20 , 23 In this case, it is required to find out why this happened:

whether the patient understood what the task was and what it meant
whether mastering this exercise is important and motivated
whether unforeseen circumstances prevented them from fulfilling it
whether the assigned exercise was not very demanding for them in their current mental state

Therefore, therapists do not consider the non-fulfilment of homework a priori as a manifestation of resistance or lack of moral qualities on the patient’s part, then as a problem that must be solved together.

However, if, despite a thorough discussion of homework and agreement on its completion, the patient repeatedly does not even attempt to complete it, does not bring records and fails to justify non-compliance, it is necessary to return to the problem analysis and goal-setting. We need to clarify with the patient whether the problem they are currently dealing with in therapy is really the most important for them, whether the goal they seek to achieve is sufficiently desirable, and whether the therapist offers to achieve is acceptable. 9 , 20

Most practicing CBT therapists report that they use homework and consider homework important for many problems 14 and believe in the role of homework in improving therapeutic outcomes. 24 , 27 Encouraging and facilitating homework is a basic skill of a CBT therapist; therefore, it is an important part of supervision. 19 , 20 , 26 Homework needs to be carefully assigned and discussed ( Box 1 ).

Case Vignette – Discussion About Not Completing Homework with an Anxious Patient

Kazantzis et al 28 advise examining the therapeutic relationship, which significantly impacts therapy adherence, to better comprehend non-cooperation with homework assignments. Data illustrating the therapist’s homework competence and the therapy outcome 29 , 30 show that the therapist is primarily responsible for their patients’ adhering to or failing to do homework. CBT therapists exhibit many interrelated automatic thoughts, assumptions, and behaviors during sessions that affect homework use in therapy. 8 , 15 In training, common negative attitudes for therapists include: “Homework will make patients feel like school and resent!” “They will feel too controlled and limited!”; “Homework will increase some ps’ sense of vulnerability!”; or “Homework will be even more stressful for stressed patients!” Another widespread belief is that the “structure” of CBT, whose homework is important, reduces spontaneity and worsens the therapeutic relationship. 15

In addition, there is some scientific support for these views of therapists’ attitudes toward homework concerning the therapeutic process. 31 The result of these attitudes is either a complete avoidance of homework assignments in a way that is not effective and consequently maintains these beliefs. 8 For example, common behaviors require supervision, such as rapidly discussing directions at the end of a session, neglecting to repeat homework, or failing to justify while designing homework. 9 The CBT Homework Project proposed a practice model 29 that emphasizes the importance of therapist beliefs, therapist empowerment, cognitive conceptualization, and the therapeutic relationship in enhancing homework practice. 23

Theoretical and empirical support for homework assignments in CBT leads most practicing CBT therapists to at least accept in principle that regular and systematic homework assignments will benefit their patients. 8 As a result, CBT therapists favour assigning homework in therapy. However, many beginning therapists encounter problems when they start designing homework (ie, selecting tasks and discussing them with the patient), assigning homework (ie, collaborating on practical aspects of completing homework), and repeating homework in sessions. 32 Incorporating homework into therapy is often superficial, hasty, poorly done, or forgotten. 16 Therefore, problems with using homework in therapy are a common supervision agenda of practicing CBT therapists.

Personal Training and Self-Reflection of the Therapist as a Supervision Intervention

CBT training students are encouraged to conceptualize the patient’s lack of homework and promote awareness of their own beliefs and responses to non-cooperation in the CBT conceptual framework. 8 Suppose the therapist fails to develop this awareness. In that case, errors in clinical judgment may occur, adversely affecting the therapeutic relationship and course of therapy. 33 Self-exercise (practicing CBT techniques and interventions as a therapist) and self-reflection (ie, process reflection) are concepts developed by Bennett-Levy et al, 34 to operationalize a useful understanding of own processes in working with patients. CBT training students are asked to become accustomed to using self-exercise and self-reflection. In a few qualitative studies, self-exercise and self-reflection have proven to improve the therapist’s self-concept, ie, self-confidence, perceived competence in one’s abilities and belief in the effectiveness of the CBT model. 34–36 Calvert et al 37 study checked the use of meta-communication in supervision from supervisees’ perspectives using the Metacommunication in Supervision Questionnaire (MSQ). There were differences in the reported frequency with which the different types of meta-communication were used. It appears that meta-communication around difficult or uncomfortable feelings in the supervisory relationship occurs less often than other components of meta-communication. 1

Below are examples of self-exercise and self-reflective exercises. The following self-assessment is developed to shape thinking before a preliminary meeting with a supervisor. Earlier knowledge has shown that supervisees and supervisors do not always share common ideas about supervision. Therefore, the supervisee could finish this self-assessment as a homework exercise before supervision. A supervisee might want to identify conversation matters that may enable a supervisor to better comprehend their requirements and needs.

Before Starting

Questions regarding previous and desired experience in supervision.

What background information do you think your supervisor requires to understand you at the start? (This may include a curriculum vitae noting appropriate previous experience). What would be the best method to convey these details? Is there any distinction between what you desire from this placement and what you feel you need? What background details about this placement and this supervisor do you have? How does this make you feel? Exists any more information that you need? What do you want and expect your supervisor to concentrate on during supervision? What roles do you want your supervisor to play with respect to you and your work? What supervisory media do you want to experience (for example, taped, “live”, or reported)? What do you intend to do about your feelings? Consider how you feel about your supervisor evaluating your work at the end of the positioning process.

Reflection on the Strengths

What are the top three strengths you want your supervisor to uncover as you enter this supervisory relationship?

List 3 points for your development that may or might not be obvious to your supervisor.

Reflection on Difficulties

Therapists regularly discover face-to-face contact with people labelled by society as coming from a specific sub-group.

Which sub-groups make you feel uneasy for whatever reason? Do you want to address this during supervision? 38

Examples of Self-Assessment in the Supervision Process

Exploring sources of stress from clinical work.

Check all that resonate for you. 39

❑ Perfectionism ❑ Fear of failure ❑ Self-doubt ❑ Need for approval ❑ Emotional depletion ❑ Unhealthy lifestyle

Which of them seems to have the greatest impact on your stress levels?

What supervisor has most regularly identified as weak points in your clinical work?

Processing Mistakes

When mistakes are processed in ways that lead to reflection, flexibility, and adjustments in how you function, it can result in learning and growth.

Consider a patient you are now working with (or have recently worked with) with whom you have experienced a therapeutic failure.

Answer the following questions while keeping this experience in mind:

What are the signs of a therapeutic failure? How can you be certain that what you are doing is not beneficial on some level? What benefits might your patient derive from failure? When did things begin to deteriorate? Which initiatives have been most effective so far, and which have been least effective? How have you been careless?
Examine your intervention choices as well as how they were carried out:
What concerns or considerations did you overlook? What is impeding your ability to be more effective? How has your empathy and compassion for this individual been harmed? How can you use this experience to help you grow?

Reflection of Therapeutics Mastery Skills

Favorite techniques.

Explain three things you have put off in your career or life because they appear risky—you have something to lose and gain.
Which therapeutic strategies or interventions stimulate you the most?
What would you call your “hidden weapon”?
What kind of patients or presenting difficulties interest you the most?
What would it take to incorporate more of the pleasure and satisfaction you receive when applying the strategies mentioned earlier into other aspects of your work? 39

The following examples from clinical supervision demonstrate how self-exercise and self-reflection can help participants understand their belief system’s impact on homework in CBT.

Supervision of Homework in Therapy

Supervision is classically mandatory for students in cognitive behavioral training and plays a crucial part in therapist development. 2 The typical structure of continuous supervision of one patient includes discussing questionnaires or scales used to measure the severity of the problem (like the Beck depression inventory), homework, events in therapy since the last session, and then discussing the agenda of the current supervision meeting (what will be done in the session, which problem will be addressed), work on a selected issue or problems, homework assignment, session summary and its evaluation by the supervisor. The supervision focuses on homework twice – first as a part of the supervised therapy and second as a part of the supervision itself ( Box 2 ).

Case Vignette – Discussion About Patient´s Homework During Supervision

Whether and how the patient completes homework is a common supervisory issue ( Box 3 ). The therapist often complains that the patient refuses to do homework or rarely does it. 8 , 16

Recording of Paul’s Automatic Thoughts

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The picture describes the vicious circle of countertransference reaction, where automatic thoughts lead to developing negative emotions, bodily reactions and behaviors. Any vicious circle components can alert the therapists that their countertransference reaction is taking place.

Case Vignette –Discussion of Setting Homework During Supervision

Homework in Supervision

Homework assignments are a common part of supervisory work. These may involve the patient’s management (eg noticing on their recording how often the therapist strengthens the patient and how and if it is rare to clarify where reinforcement would be appropriate), working on oneself (eg clarifying experiences and attitudes that lead to countertransference in a particular patient, awareness of which other patients may also occur) and theoretical study (the supervisor may advise the therapist to read a professional text that can help better understand and work with the patient). 40

The supervisor helps define a specific engagement, discusses specific therapeutic methods, touches on what methods the therapist has used and what else they may consider the role, for the most part, the implementation of strategies whose ability to use in therapy under supervision will be planned, as part of homework.

Homework assigned in supervision usually deals with mapping problems (supplementing the conceptualization of the case, evaluation, vicious circle of the problem with the patient, etc.), monitoring certain behaviors (mostly communication with the patient), or implementing new, behaviors in therapy (usually using therapeutic strategies). 12 Homework teaches the supervisee to work on self-reflection outside the supervision meetings. 41 Discussing the homework properly at the beginning of the session is important. The mentioned home exercises usually concern the work with the supervised case report of the patient. The basic questions concern homework results, discussing the obstacles in solving them and what the supervisee learned in homework. 8 The discussion gives the supervisor case management information and can point to important practice moments.

Homework Assignment

Before the end of the session, the supervisor and the supervisee agree on a homework assignment. It is optimal when homework arises from a problem addressed in the session’s main part. 8 At the beginning of supervision, proposals for homework assignments usually come from the supervisor and are discussed and recorded in writing. 40 During supervision, the supervisee creates homework assignments, and the content is discussed with the supervisee.

The Meaning of Homework

Homework must make sense for the supervisee; otherwise, he will have no motivation to do it. However, it is also important to make sense of the patient or patients and develop the therapist’s skills and competencies. It is desirable to discuss the meaning of homework in supervision.

Possible Difficulties When Completing Homework

It is advantageous to discuss the anticipated difficulties in completing homework. This has the advantage that the supervisee can prepare for possible difficulties, consider overcoming them and consult with the supervisor. Discussing difficulties helps the supervisee model and later develops the skill to discuss the patient’s homework difficulties.

The Impact of the Therapist’s Belief System

In some therapists, there can be reasons for a more complex level of conceptualization. 42 That is important when the therapist repeats certain mistakes even though they have repeatedly discussed them with the supervisor. At a directly accessible level, the situation with the patient can be described using a vicious circle. The deeper “hidden” level refers to the core beliefs and conditional rules activated in a specific situation with the patient. 40 , 43 A supervisor can use the “falling arrow” technique to map core beliefs and conditional assumptions. 43

One such way is the Therapeutic Belief System (TBS). 44 TBS is a theoretical model useful for understanding the specific beliefs, assumptions, and behaviors that therapists and patients commonly experience that could potentially affect the course of therapy. In line with the cognitive model, TBS provides a framework for identifying therapists’ and patients’ beliefs about themselves, each other, the treatment process, the emotions these beliefs can evoke, and typical behavioral reactions. For example, a therapist may see a patient as an “aggressor”, a “helpless victim”, or a “collaborator”. The participant’s own beliefs may supplement these beliefs about himself, such as “victim”, “co-worker”, “carer”, or “rescuer”. Homework assignments may be perceived by both the therapist and the patient as “hopeless”, “productive”, or simply maintaining the status quo and lead to a different emotional and behavioral response. 8 Thus, TBS can be introduced into supervision to guide the supervisee to consider whether he or she identifies with any of the therapists’ typical beliefs and behaviors outlined in the model. A simple awareness of such patterns can be a useful orientation when considering the role of attitudes and beliefs in integrating homework ( Box 4 ).

Case Vignette – Discussion About Supervisee Homework

The scheme broadly refers to mental structures that integrate and give meaning to events. 45 Schemes can be positive, negative or neutral. In CBT as a treatment for psychological disorders, we focus on dysfunctional patterns often associated with specific diagnostic presentations (for example, emotional vulnerability patterns are common in anxiety disorders). Schema is generally defined as a ubiquitous topic of cognitive functions, emotions, physiological feelings about oneself, and relations with others. 33

Therapists’ schemes run in specific therapies and do not usually signal mental health problems. 8 Therapists’ schemes are influenced by the following factors: training experiences, such as supervision and training phase, therapy model, peer group, clinical experience, and personal experience. 13 , 40 Once identified, the therapist’s scheme can be used in supervision as a starting point to discuss some of the practitioner’s views that may interfere with therapy. 8 Completing structured questionnaires can identify participants’ schemes, basic beliefs, and assumptions. Some examples of useful questionnaires are the Dysfunctional Attitudes Scale, 46 the Personal Faith Questionnaire, 47 the Young Schema Questionnaire 48 and the Therapists’ Schema Questionnaire. 49 Leahy’s Therapists’ Scheme Questionnaire is a relatively straightforward screening technique for identifying therapeutic patterns that could affect a therapeutic relationship. It consists of 46 assumptions related to the 14 most common therapeutic regimens.

Certain schemes are particularly common in CBT supervisees. These include “demanding standards”, “excessive self-sacrifice”, and “special superior person”. 49 Training therapists who identify with the “demanding standards” scheme have a somewhat obsessive, perfectionist, and controlling approach to therapy. These therapists usually have high expectations for keeping a patient’s homework and may not realize that non-compliance with homework is often part of the learning process. Therapists may expect that there is a “right” way to complete a homework assignment, leading to feelings of frustration when assignments produce different results. This may signify insecurity and a notion that if things break from the planned structure, the therapist will be exposed as “incompetent”. Many therapists identify with the “excessive self-sacrifice” pattern, the most commonly observed pattern in both novice and experienced therapists. 33 Leahy 49 proposes that these therapists overstate the importance of their patient relationships. They may fear leaving or feel guilty that they are or feel better than the patient. As a result, the therapist may engage in therapy-defeating behaviors, such as making the homework assignment to the patient’s various needs, having difficulty with appropriate assertiveness in discussing persistent patient non-cooperation, and having a tendency to avoid techniques. Such as exposure or opening of painful memories for fear that the patient will be upset.

Novice therapists who identify with the “special superior person” scheme see the therapeutic situation as an opportunity to achieve excellent results and have high-performance expectations. There may be a tendency for the patient to idealize or, conversely, to devalue or distance himself from patients who do not improve or do their homework. The presence of a “special superior” scheme can be seen as overcompensation in response to “demanding standards” and “excessive self-sacrifice”, which have the thematic connotations of “not being good enough”. The supervision session sets the supervisee in a situation where the supervisor supervises homework through videotaped therapeutic sessions utilizing a cognitive therapy scale (CTS). 50 Feelings of superiority and exceptionality can, in some cases, be a way of dealing with the feelings of inferiority that they experience, that their use of homework is judged in this way.

In addition to recognizing the general responses to the scheme that most training students encounter, the supervisor should help the supervisor become aware of his or her idiosyncratic beliefs and coping styles, which some patients may trigger ( Box 5 ). The supervisor should encourage the supervisee to pay special attention to the “overlapping patterns” in which the therapist’s scheme and the patient’s scheme overlap, leading to the over-identification of the therapist with the patient. 33

Case Vignette – The Supervisor Advises the Therapist to Work with Core Beliefs and Conditional Rules

Homework in Supervisor Training

For supervisors, their supervisors’ training is important. An important part of this training is the practice of self-reflection, which should be requested directly in the meeting and as homework. It can be a task to capture situations in supervision in which they do not feel comfortable using the vicious circle, cognitive restructuring of automatic negative thoughts in these situations, capturing thoughts, emotions, bodily sensations and behaviors in situations where they are aware that they are experiencing countertransference reactions to the supervised therapist. It is also important that in their homework, they reflect on their concentration level during supervision sessions and consider what supervision skills they have used or what they have learned for the next session. A typical complex homework in supervision training is a video recording of supervision sessions and their analysis. The recorded supervision and analysis are then analyzed in the next supervision training meeting.

This article is designed as an overview of views and experiences. Its important element is work samples. This is also a limitation of this article. Assignment of homework in supervision and therapist and supervisor training lacks scientific information about its effectiveness. Nevertheless, assigning homework is an important part of cognitive behavioral therapy. We know quite well about its meaning in prescribing for patients. Less is known about their meaning and effectiveness in supervision. The supervisee encounters problems completing homework assignments for her patients that she brings to the supervisee. Why the patient does not complete the homework may be his problem, but his therapist may also have a part in it his requirements, which include how the homework is assigned, its suitability for the given patient, timing, and complexity. Homework can also belong to the training of supervisors and the supervision of supervision. Here, we do not know any research evidence about their effectiveness in using the most important part of supervision, the patient; however, they are experienced by supervisors and supervisees as useful and meaningful.

Homework in supervision and supervision requires further reflection on their meaning and subsequent research, which should examine their significance for the supervisee’s competence (supervisee) and the ultimate impact on the patient himself.

Homework presents one of the cornerstones of cognitive-behavioral therapy, CB supervision and the training of CBT supervisors. If applied consistently and collaboratively, homework enhances therapeutic outcomes and increases the patient’s self-confidence. Setting and maintaining a fruitful working alliance for homework can be challenging – issues with homework present one of the common reasons to seek a supervisory consultation. Supervision then focuses on examining the specific case and experienced problems, factors in the interaction between the therapist and their patient, and the therapist’s automatic thoughts, schemas, and behaviors that might maintain the issue. There are several ways to address this topic in supervision. Homework is usually part of supervision because of its usefulness. The supervised therapist may be given similar tasks as the patient receives in therapy: to describe the automatic thoughts that occur to him while guiding the patient, to test them and look for a more rational response, to conduct behavioral experiments, to clarify the core beliefs and conditioned assumptions that influence the formation of the therapeutic relationship, experiments with adequate communication with the patient and others. A therapist’s self-experience through practice can help them improve their therapeutic work.

Acknowledgments

This paper was supported by the research grant VEGA no. APVV-15-0502 Psychological, psychophysiological and anthropometric correlates of cardiovascular diseases.

The authors report no conflicts of interest in this work.

Last edited on September 9, 2020

Homework in CBT

Table of contents, why do homework in cbt, how to deliver homework, strategies to increase confidence.

Homework assignments in Cognitive Behavioural Therapy (CBT) can help your patients educate themselves further, collect thoughts, and modify their thinking.

Homework is not something that you just assign randomly. You should make sure you:

tailor the homework to the patient
provide a rationale for why the patient needs to do the homework
uncover any obstacles that might prevent homework from being done (i.e. - busy work schedule, significant neurovegetative symptoms)

Types of homework

Types of homework assignments.

You should also decide the frequency of the homework should be assigned: should it be daily, weekly?

If your patient does not do homework, that’s OK! Explore as a team, in a non-judgmental way, to explore why the homework was not done. Here are some ways to increase adherence to homework:

Tailor the assignments to the individual
Provide a rationale for how and why the assignment might help
Determine the homework collaboratively
Try to start the homework during the session. This creates some momentum to continue doing the homework
Set up systems to remember to do the assignments (phone reminders, sticky notes
It is better to start with easier homework assignments and err on the side of caution
They should be 90-100% confident they will be able to do this assignment
Covert rehearsal - running through a thought experiment on a situation
Change the assignment - It is far better to substitute an easier homework assignment that patients are likely to do than to have them establish a habit of not doing what they had agreed to in session
Intellectual/emotional role play - “I’ll be the intellectual part of you; you be the emotional part. You argue as hard as you can against me so I can see all the arguments you’re using not to read your coping cards and start studying. You start.”

Help & FAQ

How to Supervise the Use of Homework in Cognitive Behavior Therapy: The Role of Trainee Therapist Beliefs

Research output : Contribution to journal › Article › Research › peer-review

Encouraging and facilitating homework completion is a core cognitive behavior therapy (CBT) skill. Consequently, it represents an important part of training practitioners. Oftentimes the process of integrating homework into therapy is rushed, poorly executed, or forgotten, and trainees are surprised to find that some patients do not complete homework. We advocate for increased therapist responsibility in accounting for homework nonadherence. Therefore, problems with the use of homework in therapy are frequently an agenda item in the supervision of trainee cognitive behavior therapists. In our experience, trainee CBT practitioners exhibit a number of interrelated automatic thoughts, assumptions, and in-session behaviors that influence their use of homework assignments. The Cognitive Behavior Therapy Homework Project has proposed a "model for practice" to guide the use of homework in CBT [Kazantzis, N., MacEwan, J., & Dattilio, F. M. (2005). A guiding model for practice. In: Kazantzis, N., Deane, F. P., Ronan, K. R., & L'Abate, L. (Eds.), Using homework assignments in cognitive behavior therapy (pp. 359-407). New York: Routledge]. The present article will draw from those practice recommendations and discuss the role and impact of the therapeutic relationship and therapist beliefs on the use of homework assignments, with reference to the different levels of CBT conceptualization. Clinical examples from the supervision of trainees enrolled in the practicum component of the Massey University Postgraduate Diploma in Cognitive Behavior Therapy are used to illustrate supervising the use of homework assignments.

Access to Document

10.1016/j.cbpra.2006.08.004

Empowerment Through Interaction: The Magic of Interactive Therapy Homework

The power of interactive therapy homework.

Interactive therapy homework plays a significant role in the therapeutic process, providing clients with a valuable tool for self-reflection, growth, and progress. By engaging in therapeutic assignments outside of session time, clients can actively participate in their own healing journey. This section aims to explore the role and benefits of interactive therapy homework.

Understanding the Role of Homework in Therapy

Homework in therapy goes beyond traditional academic assignments. It involves specific tasks and exercises designed to reinforce the concepts discussed during therapy sessions and encourage clients to apply new skills in their everyday lives. The purpose of therapeutic homework is to extend the therapeutic experience beyond the confines of the therapy room, empowering clients to take an active role in their own well-being.

Through homework, clients have the opportunity to practice and integrate the strategies, techniques, and insights gained during therapy. They can apply these new skills to real-life situations, fostering personal growth and self-awareness. Additionally, therapeutic homework allows clients to reflect on their progress, identify patterns, and gain deeper insights into their thoughts, emotions, and behaviors.

The Benefits of Interactive Therapy Homework

Interactive therapy homework offers numerous benefits for clients. It enhances the therapeutic process by promoting continuity between sessions and creating a bridge for ongoing growth and learning. Some key benefits include:

Increased Engagement and Accountability : Interactive therapy homework encourages clients to actively engage with the therapeutic process outside of sessions. It fosters a sense of responsibility and accountability, as clients take ownership of their own progress and development.
Personalized Learning : Interactive therapy homework allows for customized assignments tailored to each client’s individual needs and goals. Therapists can provide exercises and activities that target specific areas of concern, helping clients work through challenges and develop new coping strategies.
Application of Techniques : By practicing therapeutic techniques and strategies in real-life situations, clients can strengthen their skills and build confidence in their ability to manage difficult emotions and situations. This practical application facilitates the integration of new habits and behaviors.
Continued Progress and Momentum : Interactive therapy homework helps maintain the momentum between therapy sessions. It provides clients with ongoing opportunities for growth and progress, ensuring that the therapeutic journey continues even outside the therapy room.
Deeper Self-Reflection : Through interactive therapy homework, clients have dedicated time and space to reflect on their experiences, thoughts, and emotions. This self-reflection deepens their understanding of themselves and their patterns, fostering personal insight and growth.

By incorporating interactive therapy homework into the therapeutic process, therapists can enhance the effectiveness and impact of their work with clients. It empowers clients to actively participate in their own healing and transformation, leading to long-lasting positive change.

In the next section, we will explore the different tools and platforms available for interactive therapy homework, providing therapists and clients with a range of options to support their journey towards growth and well-being.

Interactive Therapy Homework Tools

To facilitate interactive therapy homework, various therapeutic homework portals have been developed. These portals serve as digital platforms that enable therapists and clients to engage in interactive and collaborative homework assignments. Let’s explore the concept of therapeutic homework portals and the different features and functionality they offer.

Introduction to Therapeutic Homework Portals

Therapeutic homework portals are online platforms designed to enhance the effectiveness of therapy by providing a centralized space for therapists and clients to collaborate on assignments. These portals offer a range of tools and resources to support the therapeutic process outside of therapy sessions. By leveraging technology, therapeutic homework portals create a convenient and accessible way to engage in interactive therapy homework.

Therapists can use these portals to customize and assign homework tasks to their clients, tailored to their specific needs and goals. Clients, on the other hand, can access their assigned homework, complete the tasks, and track their progress within the portal. This interactive and collaborative approach to therapy homework fosters greater engagement and accountability, ultimately enhancing the therapeutic outcomes.

Exploring Different Features and Functionality

Therapeutic homework portals come with a variety of features and functionalities that enhance the interactive and collaborative nature of therapy homework. Here are some common features you may find in these platforms:

Customization : Therapists can create personalized homework assignments for their clients, aligning with their treatment goals and specific therapeutic approaches. This customization allows for a tailored and targeted approach to therapy homework.
Progress Tracking : These portals often include tools to track and monitor clients’ progress. Therapists can review completed assignments, provide feedback, and make adjustments to the treatment plan as needed. Clients can also monitor their own progress, gaining insights into their achievements and areas for improvement.
Resource Libraries : Many therapeutic homework portals provide access to a wide range of resources, such as therapeutic worksheets, journal prompts, mindfulness exercises, and educational materials. These resources enrich the therapy experience and provide clients with additional tools for self-reflection and growth.
Communication and Messaging : Some portals offer communication features that allow therapists and clients to exchange messages securely within the platform. This facilitates ongoing communication, clarification of assignment instructions, and the ability to address any questions or concerns that arise during the homework process.
Reminders and Notifications : To promote consistency and adherence to therapy homework, these portals often include reminder features. Clients can receive notifications and reminders about upcoming assignments, ensuring they stay on track with their therapy goals.

Therapeutic homework portals provide a convenient and efficient way for therapists and clients to engage in interactive therapy homework. By utilizing the features and functionality offered by these platforms, therapists can effectively support their clients’ progress and empower them to take an active role in their therapy journey. To learn more about how therapeutic homework can be integrated into practice, check out our article on therapeutic assignments .

How Interactive Therapy Homework Works

Interactive therapy homework is a valuable tool that allows clients to actively participate in their therapeutic journey outside of therapy sessions. It involves providing customized assignments tailored to the individual needs of each client and tracking progress to monitor goals. This approach empowers clients to take an active role in their own growth and development.

Customized Assignments for Individual Needs

Interactive therapy homework is designed to address the unique needs of each client. Therapists create assignments that align with the client’s specific goals and challenges. These assignments can take various forms, such as journaling exercises, reflection questions, or audiovisual resources. The goal is to provide clients with opportunities for self-reflection, exploration, and skill development.

Customized assignments allow clients to delve deeper into their thoughts, emotions, and behaviors, promoting self-awareness and personal growth. By tailoring assignments to individual needs, therapists can provide targeted support and guidance, helping clients overcome obstacles and achieve their therapeutic goals.

Tracking Progress and Monitoring Goals

Tracking progress is an essential component of interactive therapy homework. Therapists utilize various tools and techniques to monitor client progress and measure the effectiveness of the assigned tasks. This tracking process helps therapists gain insights into client growth and provides valuable data for future therapy sessions.

One effective way to track progress is through the use of therapy homework trackers or therapy homework journals . These tools enable clients to record their experiences, observations, and insights related to the assigned tasks. By reviewing these records, therapists can gain a comprehensive understanding of the client’s progress, identify areas of improvement, and make necessary adjustments to the therapeutic approach.

Tracking progress also allows therapists to celebrate client achievements and milestones, fostering a sense of accomplishment and motivation. By consistently monitoring goals and progress, therapists can adapt and modify assignments as needed, ensuring that clients continue to grow and evolve throughout their therapeutic journey.

Integrating interactive therapy homework into practice requires therapists to implement best practices and provide support to clients in utilizing these assignments effectively. By incorporating customized assignments and tracking progress, therapists can facilitate client engagement , enhance therapeutic outcomes, and empower clients to take an active role in their own healing process.

Empowering Clients through Interaction

Interactive therapy homework can be a powerful tool in empowering clients to take an active role in their therapeutic journey. By incorporating interactive elements into therapy assignments, clients experience increased engagement and accountability, as well as the opportunity to build essential skills and apply therapeutic techniques.

Increased Engagement and Accountability

One of the key benefits of interactive therapy homework is the increased engagement it fosters between clients and their therapeutic process. Traditional homework assignments often involve completing worksheets or journaling, which can feel disconnected and passive. However, with interactive therapy homework, clients actively participate in activities that require their engagement and input.

By using interactive therapy assignments , such as digital exercises, online activities, or virtual role-plays, clients can immerse themselves in the therapeutic process. These interactive elements encourage clients to reflect, explore, and apply therapeutic concepts in real-life scenarios. This active involvement creates a sense of ownership and investment in their own growth and progress.

Furthermore, interactive therapy homework promotes accountability. Clients have the opportunity to track their progress, monitor goals, and reflect on their experiences. This self-monitoring aspect enhances their commitment to the therapeutic process and encourages a sense of responsibility for their own well-being. A therapy homework tracker can be a valuable tool for both clients and therapists to monitor progress and provide support where needed.

Building Skills and Applying Techniques

Interactive therapy homework allows clients to build important skills and apply therapeutic techniques in a practical context. With traditional homework, clients may learn about various strategies and techniques during therapy sessions but struggle to apply them in their daily lives. However, through interactive therapy assignments , clients have the opportunity to practice and integrate these techniques outside of the therapy room.

For example, clients can engage in activities that promote mindfulness , cognitive restructuring , or behavioral experiments . These interactive assignments provide clients with a safe space to experiment with new ways of thinking, behaving, and responding to challenging situations. By actively engaging in these activities, clients can develop and reinforce the skills and techniques they are learning in therapy.

The process of applying therapeutic techniques outside of therapy sessions allows clients to experience firsthand the benefits and effectiveness of these approaches. It also provides valuable feedback that can be discussed and explored during therapy sessions, further enhancing the therapeutic process.

By empowering clients through interaction, interactive therapy homework creates an environment that fosters engagement, accountability, skill-building, and practical application of therapeutic techniques. This collaborative approach between clients and therapists promotes a sense of active participation and ownership in the therapeutic process, ultimately leading to more meaningful and transformative outcomes.

Integrating Interactive Therapy Homework into Practice

To fully harness the benefits of interactive therapy homework , therapists and practitioners should follow best practices and provide support to their clients in utilizing these tools effectively.

Best Practices for Therapists and Practitioners

Assessment and Customization : Begin by thoroughly assessing the client’s needs and goals. Tailor the interactive therapy homework assignments to address their specific challenges and promote growth. Consider using a therapy homework planner or a homework management system to organize and track assignments effectively.
Clear Instructions : Clearly explain the purpose, instructions, and expectations for each homework assignment. Use simple language and provide examples, ensuring that clients understand what is required of them.
Collaborative Approach : Involve clients in the creation of their homework assignments. Encourage them to provide input and suggest activities that resonate with their interests and preferences. This collaborative approach enhances engagement and ownership.
Realistic and Achievable Goals : Set realistic goals that align with the client’s abilities and circumstances. Break larger goals into smaller, manageable tasks that can be accomplished within the designated timeframe.
Flexibility and Adaptability : Recognize that clients may face challenges or encounter obstacles when completing their homework assignments. Be flexible and willing to modify assignments when necessary, ensuring they remain relevant and achievable.
Regular Review and Feedback : Schedule regular check-ins to review clients’ progress and provide feedback on their completed assignments. Positive reinforcement and constructive feedback can motivate clients to continue their growth journey.

Supporting Clients in Utilizing Interactive Therapy Homework

Education and Orientation : Provide clients with clear instructions on how to access and navigate the therapeutic homework portal or any other digital platforms used for interactive therapy homework. Offer tutorials or training sessions if necessary.
Guidance and Resources : Offer guidance on how to use the available tools and features within the therapeutic homework portal . Provide resources such as therapeutic homework templates , worksheets , or activities that can assist clients in completing their assignments.
Encouragement and Motivation : Regularly communicate with clients to offer encouragement and remind them of the benefits of completing their interactive therapy homework. Show genuine interest in their progress and celebrate their achievements.
Addressing Barriers : Identify any potential barriers that may hinder clients from engaging in their interactive therapy homework. Collaborate with them to develop strategies to overcome these barriers, whether they are related to time management, motivation, or other factors.
Tracking and Accountability : Utilize a therapy homework tracker or a similar tool to monitor clients’ completion of their assignments. This tracking mechanism helps both therapists and clients stay accountable and provides a visual representation of progress.

By following best practices and providing ongoing support, therapists and practitioners can integrate interactive therapy homework seamlessly into their practice. This integration promotes engagement, accountability, and skill development, leading to more effective therapy outcomes.

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The Role of Homework Engagement, Homework-Related Therapist Behaviors, and Their Association with Depressive Symptoms in Telephone-Based CBT for Depression

Original Article
Open access
Published: 22 July 2020
Volume 45 , pages 224–235, ( 2021 )

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Elisa Haller 1 &
Birgit Watzke 1

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Telephone-based cognitive behavioral therapy (tel-CBT) ascribes importance to between-session learning with the support of the therapist. The study describes patient homework engagement (HE) and homework-related therapist behaviors (TBH) over the course of treatment and explores their relation to depressive symptoms during tel-CBT for patients with depression.

Audiotaped sessions (N = 197) from complete therapies of 22 patients (77% female, age: M = 54.1, SD = 18.8) were rated by five trained raters using two self-constructed rating scales measuring the extent of HE and TBH (scored: 0–4).

Average scores across sessions were moderate to high in both HE ( M = 2.71, SD = 0.74) and TBH ( M = 2.1, SD = 0.73). Multilevel mixed models showed a slight decrease in HE and no significant decrease in TBH over the course of treatment. Higher TBH was related to higher HE and higher HE was related to lower symptom severity.

Conclusions

Results suggest that HE is a relevant therapeutic process element related to reduced depressive symptoms in tel-CBT and that TBH is positively associated with HE. Future research is needed to determine the causal direction of the association between HE and depressive symptoms and to investigate whether TBH moderates the relationship between HE and depressive symptoms.

Trial Registration

ClinicalTrials.gov NCT02667366. Registered on 3 December 2015.

Confirmatory Factor Analysis of the Kessler-6 Psychological Distress (K6) Scale in a Community Sample of People Living with Severe and Persistent Mental Illness: a Bifactor Model

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Introduction

Therapeutic homework in terms of inter-session activity presents a central component of psychotherapy and is particularly inherent to cognitive behavioral therapy (CBT; Beck et al. 1979 ). The core principle of this treatment is to equip patients with tools to change thoughts, behaviors, emotions, and their interplay. Homework may be defined as activities carried out between sessions in order to practice skills outside of therapy and to generalize to the natural environment (Kazantzis and L’Abate 2007 ; Lambert et al. 2007 ). Rather than exclusively discussing problems in an isolated setting, patients are encouraged to address the problem in their everyday life with the intention to produce and maintain a therapeutic effect (Lambert et al. 2007 ). The theorized mechanisms of the effect of homework build upon the skills-building approach of CBT (Beck et al. 1979 ; Detweiler and Whisman, 1999 ), as therapeutic exercises provide an opportunity for the patient to gather information and practice newly gained skills. Ultimately, practicing skills outside therapy helps becoming aware of the problem and consolidating new beliefs and behaviors (Beck et al. 1979 ). Homework thus serves as a means of transferring strategies outside the therapy context and enables the patient to practice new skills in real-life situations in order to maintain therapeutic gain (Kazantzis and Ronan 2006 ).

Homework is a commonly studied process variable in CBT and has empirically been investigated primarily in association with treatment outcome. Previous research has demonstrated that a high level of homework compliance is related to improvements in depressive symptoms (e.g., Kazantzis et al. 2010 ). Meta-analyses have established correlational evidence for the homework compliance and outcome relationship (e.g., Mausbach et al. 2010 ) as well as experimental evidence for the superiority of treatments that incorporate homework over treatments without homework (Kazantzis et al. 2010 , 2016 ).

It has previously been noted that an “evidence-based” assessment of homework compliance (Dozois 2010 , p. 158) requires the consideration of qualitative aspects of homework completion throughout the course of the treatment (Dozois 2010 ; Kazantzis et al. 2010 , 2017 ). This has been neglected in previous studies on the homework-outcome relationship, which rely solely on adherence or compliance measures that focus on the proportion of completed homework or global single-item measures of whether the patient attempted the homework or not (e.g., Bryant et al. 1999 ; Aguilera et al. 2018 ). In a recent systematic review of homework adherence assessments in major depressive disorder (MDD), Kazantzis et al. ( 2017 ) found that only 2 out of 25 studies reported the measures that addressed the quality of homework completion. Furthermore, the single-item Assignment Compliance Rating Scale (ACRS; Primakoff et al. 1986 ) does not capture the depth of HE and the Homework Rating Scale (HRS; Kazantzis et al. 2004 ) is a client self-report measure, which might over- or underestimate homework compliance compared to objective measures. Studies increasingly put effort on focusing on qualitative aspects of homework completion. For this reason, the term and concept of homework engagement (HE) has been deemed relevant: it refers to the extent to which a patient has completed homework in an elaborate and clinically meaningful manner (Dozois 2010 ; Conklin and Strunk 2015 ). Furthermore, less empirical attention has been paid to underlying mechanisms going beyond patient factors, including therapist behaviors influencing HE and their relation to depressive symptoms.

Homework-Related Therapist Behaviors

Theoretical considerations and clinical recommendations of therapist behaviors related to homework (TBH) mainly build on four strategies suggested by Beck et al. ( 1979 ): (1) Homework should be described clearly and should be specific; (2) homework should be assigned with a cogent rationale; (3) patients’ reactions and should be elicited and in order to troubleshoot difficulties; (4) progress should be summarized when reviewing homework. Expert clinicians have also pointed out the value of formulating simple and feasible homework tasks and emphasized the patient involvement when developing homework assignments that are agreeable to the patient (Kazantzis et al. 2003 ; Tompkins 2002 ). Moreover, factors such as the match between the assignment and the client, as well as the wording of the homework task should be considered (Detweiler and Whisman 1999 ).

The suggested domains have also received some empirical attention. To our knowledge, four studies have focused on TBH in face-to-face treatment of MDD, which provide inconsistent findings. First, Startup and Edmonds ( 1994 ) investigated whether patient ratings of therapist behaviors promoting homework compliance were associated with therapist-rated homework compliance in a sample of 25 patients. The results did not demonstrate a significant relation between any facet of TBH (providing rationale, clear description, anticipation of problems, involving the patient) and homework compliance, which was largely attributed to ceiling effects of the patients’ ratings of TBH. Second, Bryant et al. ( 1999 ) assessed observer-rated homework compliance and TBH (reviewing previous assignment, providing rationale, clearly assigning and tailoring, seeking reactions and troubleshooting problems) in 26 depressed patients receiving cognitive therapy (CT). The study confirmed that patients that are more compliant experienced greater symptom improvement, and demonstrated a non-significant trend that suggests a relation between the overall score of the therapist homework behavior scale and homework compliance. Item-based analyses, however, demonstrated that therapist reviewing (TBH-R), but not therapist assigning behavior (TBH-A), was related to homework compliance. Third, in a sample of adolescents with depression, Jungbluth and Shirk ( 2013 ) demonstrated that providing a strong rationale and allocating more time in the beginning of treatment predicted greater homework compliance in the subsequent session, especially for initially resistant individuals. Fourth, the most recent study, conducted by Conklin et al. ( 2018 ), evaluated three classes of TBH in a sample of 66 patients with MDD undergoing CT. The authors reported that TBH-A, but not TBH-R were predictive of HE in the early sessions of CT, which stands in contrast to the findings of Bryant et al. ( 1999 ).

In consideration of the therapist’s prominent role in making use of therapeutic homework and the available inconclusive findings, the contribution of TBH to HE and their relation to depressive symptoms needs further exploration.

Homework Engagement in Telephone-Based CBT

The introduction of low-intensity CBT led to a way of delivering evidence-based treatments that is characterized by limited therapist input, technology-support, and increased use of self-help. These features are conflated in telephone-based CBT (tel-CBT). Tel-CBT puts emphasis on patients’ independent engagement with the therapeutic contents outside of therapy sessions by making systematic use of homework activities. The therapist plays an active role in structuring the treatment, providing input, and facilitating the comprehension and the use of homework. To the best of the authors’ knowledge, a limited number of studies with regard to homework in guided self-help and technology-supported treatment exists. One study investigating overall and component-specific homework compliance in an internet-based treatment with minimal therapist guidance found that overall homework compliance predicted 15% of the reductions in depressive symptoms (Kraepelien et al. 2019 ). Another study investigated TBH-R and homework completion in a telephone-delivered CBT (Aguilera et al. 2018 ). The authors found that the number of sessions in which a patient completed homework was related to a decrease in depressive symptoms at the end of treatment. This relationship disappeared when taking into account TBH-R, which, however, was positively associated with symptom reduction. These findings suggest that aspects of TBH are important factors for improved symptom outcome, but that TBH does not moderate the effect of homework compliance on improved symptom outcome (Aguilera et al. 2018 ).

Given the emphasis on patients’ contribution and self-reliance in the present treatment format, the assessment of HE might be a relevant process variable related to treatment outcome and an important therapy process that therapists can build upon. We would like to extend the current literature by using HE—a construct that is conceptually different from homework compliance and adherence—and by evaluating all sessions of the treatment (on average 9 sessions). This allows gaining a deeper understanding of the course of HE and TBH as well as the potential association between these variables and depressive symptoms.

Aim of the Current Study

The overall aim of the study is to provide insight into the occurrence and the course of HE and TBH in tel-CBT for depression. Additionally, first evidence on the relationship between HE, TBH, and depressive symptoms should be provided. Three objectives are pursued: (1) The assessment of the amount of homework, the proportion of different homework types, and the types of difficulties faced by patients when engaging with homework; (2) the description of initial status and course of HE and TBH in tel-CBT; (3) first examination of the relation between HE, TBH, and depressive symptoms over the course of the treatment.

The current study draws on data from a randomized controlled trial (RCT; Haller et al. 2019 ) investigating the effectiveness of tel-CBT compared to treatment as usual. Information on detailed study procedures and methods of the overarching RCT can be found in the study protocol (Watzke et al. 2017 ). The trial was approved by the local Ethics Committee. Inclusion criteria for the study were a PHQ-9 score of > 5 and ≤ 15, a diagnosis of mild or moderate depression according to ICD-10 (F32.0, F32.1, F33.0, F33.1), and the provision of a written informed consent. Patients were excluded, if they showed suicidality (item 9 > 0 on PHQ-9) or severe or chronic depression (F32.2, F34.1), if their physical or mental condition did not allow completion of questionnaires, if they were not proficient in the German language, or if they were in psychotherapeutic or psychological treatment at the time of intake or 3 months prior. For the main trial, 152 patients were screened for eligibility, of which 54 were included and randomized to either intervention or control group.

Data of each therapy session from patients randomized in the intervention group, i.e., those who received and completed the tel-CBT ( N = 24), were used. We included data from all patients of which more than 80% of the therapy sessions were available and audio-recorded. The sample for the current study was necessarily reduced to N = 22 because from two patients the majority of therapy sessions was missing due to technical failure to record. The two excluded patients did not differ from the intervention group in clinical status and sociodemographic variables with the exception that their age is in the lower range.

For the included 22 patients, three therapists who were employed at the University’s outpatient clinic were involved in providing tel-CBT. All therapists were female and 34 years old on average ( SD = 5.9). The therapists were clinical psychologists with previous experience in treating patients with depression, and were in advanced training of CBT (current duration of training: M = 4.3 years, SD = 1.5). They received specific training in tel-CBT prior to the study and regular supervision by a senior clinician and researcher (BW) during the treatment provision.

Tel-CBT starts with a personal face-to-face session with the therapist and comprises 8–12 subsequent telephone sessions, which last between 30 and 40 min. The treatment program is called “Creating a balance” and is conceptualized as a guided self-help CBT delivered over the telephone. The content is based on core CBT elements—psychoeducation, behavioral activation, cognitive restructuring, and relapse prevention—within a total of eight chapters. The intervention entails a treatment manual for therapists and a workbook for patients to read and practice skills in between sessions. Each chapter is structured in a psychoeducational part with reading materials and case vignettes and a practical part with step-by-step instructions for exercises (i.e., homework). Copies of additional worksheets to complete homework are provided at the end of each chapter. Therapists were instructed to adhere closely to the treatment manual. This included agreeing upon a homework assignment in each therapy session, and reviewing the previously assigned homework at the beginning of the subsequent therapy session. The types of homework in the treatment manual were classified as: (1) Psychoeducational homework, including reading materials and case vignettes; (2) behavioral homework, including scheduling and undertaking pleasant activities; (3) cognitive homework, including replacing dysfunctional thoughts; (4) self-monitoring homework, referring to observing and monitoring thoughts and emotions; and (5) relapse prevention homework, including recognizing warning signs and establishing an emergency plan.

Measures and Assessment

Global Homework Engagement Scale (GHES). We developed an instrument measuring global HE independent of the type of homework assigned. The previously established homework engagement scale (HES) for CT by Conklin and Strunk ( 2015 ) served as a basis for the instrument. GHES consists of seven items regarding quantitative and qualitative aspects of homework completion. Each item is described in detail and is assessed on a 5-point Likert scale, varying from 0 ( not at all ) to 4 ( considerably ). Each of the five item manifestations contains a verbal anchoring tailored to the respective item in order to determine specific criteria connected to the rater’s decision, helping to ensure a uniform understanding of each item’s characteristics. The seven items cover the following aspects of HE: (1) Extent to which patients engaged with homework tasks; (2) whether and to which extent patients carried out homework as agreed upon; (3) whether and to which extent patients applied learnt strategies in difficult times; (4) the intensity of HE; (5) whether and to which extent patients faced difficulties when carrying out homework; (6) whether and to which extent patients could benefit from completed homework tasks; (7) estimated time that patients spent on HE. Additionally, and similarly to HES by Conklin and Strunk ( 2015 ), the scale contains two items which serve as a homework log. In the first log-item, homework that was reportedly completed from the previous session were written down by the raters. For the second log-item, research assistants recorded homework assignments for the next session before the rating procedure started. This procedure ensured that raters were informed about which previously assigned homework the discussion in a session is referring to. For the global GHES score, an average score of items 1 to 7 is calculated with higher scores indicating more HE.

Scale for Therapeutic Homework Assignment and Review (StHAR). An instrument to assess TBH was constructed for the purpose of this study. The instrument consists of eight items covering the process of assigning the upcoming homework (TBH-A) and the process of reviewing previously assigned homework (TBH-R). All items are assessed on a 5-point Likert scale, varying from 0 ( not at all ) to 4 ( considerably ). Each item is described in detail and contains a verbal anchoring for each item manifestation. The five items covering TBH-A build the subscale StH-A and comprise: (1) providing a rationale for the homework; (2) tailoring the homework to the individual situation; (3) addressing potential challenges of completing the homework; (4) specifying the homework; (5) ensuring comprehension of the homework. The subscale StH-R includes three items relating to TBH-R: (1) extent of discussing previous homework; (2) drawing conclusions of the homework; and (3) using homework to strengthen self-efficacy expectation of patient. The global StHAR score is calculated with an average score of all items, with StH-A items used from the previous session and StH-R items used from the subsequent session. Higher scores indicate a larger extent of TBH. Items from both scales are displayed in Table 1 . The German versions of the scales can be retrieved upon request from the corresponding author.

Patient Health Questionnaire (PHQ - 9) . Depressive symptoms were assessed at the beginning of each session using the German version of the PHQ-9 (Löwe et al. 2002 ). Nine items regarding primary and secondary depression symptoms are assessed on a 4-point Likert scale and build a sum score between 0 and 27. Therapists went through each item of the PHQ-9 right at the beginning of each session as part of the symptom monitoring. Patients had a copy of the PHQ-9 in front of them, answering whether the symptom was available 0 ( none of the days ) to 3 ( almost every day ). Although originally developed as a self-report measure, telephone administration of the PHQ-9 seems to be a reliable and valid procedure to assess depression (Pinto-Meza et al. 2005 ).

Ratings of Tel-CBT Sessions

Audio recordings were available for all therapy sessions of the included 22 treatments. All available recordings of per protocol therapy sessions were included in the dataset. We did not include the initial face-to-face appointment, as this was not relevant for the assessed process variables. From 210 tel-CBT sessions that had taken place within this sample, we were able to rate 194 sessions (92.4%). We had to exclude sessions that deviated from the treatment manual ( n = 4) or where audio recordings were not available or unusable due to technical failure to record the session, or due to poor quality of the recording ( n = 12), respectively. Deviation of the treatment manual is defined as a session that did not target the planned content. This was the case, when therapists had to react to a crisis situation of the patient. The mean duration of one telephone session was 43 min ( SD = 9.6).

Raters and Rater Training

HE and TBH were rated by five independent raters (one Doctoral candidate and four Master-level students in clinical psychology). All raters were blind to treatment outcome of the patients. During a period of 4 weeks, raters received 54 hours of training in the employed treatment manual and the use of the rating instruments. Training consisted of discussing the content of the treatment manual, particularly homework types in the tel-CBT. Furthermore, defining adequate and competent therapist behaviors regarding assignment and review of homework were discussed. Following the training phase, three successive trial ratings were completed by the raters. Each trial rating was discussed and in case of disagreement, the wording of the items were refined until consensus was reached. Prior to the rating phase, three therapy sessions from two excluded cases were randomly selected and rated by all five raters in order to examine initial inter-rater reliability (IRR). Calculation of intra-class correlation coefficients (ICC) in a two-way random model ICC (2,2) (Shrout and Fleiss, 1979 ) revealed an average ICC (2,2) of .91 and a median ICC (2,2) of .93 across all raters and all items of GHES, and an average ICC (2,2) of .81 and a median ICC (2,2) of .88 across all raters and all items of StHAR. This result indicated that IRR was high, and that formal ratings could start subsequently.

Rating Procedure

All items were rated on a 5-point Likert scale in order to determine the estimated extent of patient`s HE as well as the extent of TBH. Raters were encouraged to take notes while listening to the audio file and rate all items at the end of the session. Of the 197 eligible audio recordings, each rater was randomly assigned between 32 and 38 sessions for the main rating. Session allocation was stratified by therapist, patient, and treatment phase (phase I: sessions 1–4; phase II: sessions 5–9). A subsample of therapy sessions was double-coded in order to establish IRR. 40% of the total amount of sessions were drawn to carry out double-ratings resulting in a total of 57 to 62 sessions rated per rater. Each rater was paired with every other rater an approximately equal number of times. For the double-rated sessions, the average score of the rater pair for each item was used in the final analyses.

Statistical Analysis

As GHES and StHAR are newly developed rating instruments, analyses of the psychometric properties were conducted before turning to the research questions under investigation. We calculated Pearson`s r for corrected item-total-correlations and coefficient omega (ω) to measure internal consistency of both scales. IRR was assessed by calculating ICC in a two-way random model (ICC 2,2 ) (Shrout and Fleiss 1979 ) testing for absolute agreement between two raters and within one rater, respectively.

In order to meet research objective one, the types of homework assigned as well as types of difficulties faced when completing homework are reported. Moreover, descriptive statistics (means and standard deviations) of the individual items and the total scores of the scales GHES and StHAR (including subscales StH-A and StH-R) are presented. For research objective two, multilevel mixed models (MLM) were applied to examine between- and within-patient variability of HE and TBH over the course of treatment in a nested data set. In two-level models HE and TBH assessed at each of the nine telephone sessions (level 1) are modelled within each of the 22 individuals (level 2). The inter-individual variability in terms of initial status and growth of HE and TBH are modelled at level 2. For research objective three, MLM was analysed with depressive symptoms measured with PHQ-9 defined as criterion on level 1. Depressive symptoms were assessed in each session. HE of the same session, and TBH (consisting of TBH-A of the previous session and TBH-R of the current session), were gradually introduced as time-varying predictors of the session-specific symptom severity. In total, five stepwise built multilevel models were calculated. First, the null or unconditional model was created, including the intercept and the random term (null-model). Second, the null-model was expanded by adding a random slope for time (model 1). Third, one time-varying predictor (HE) was introduced into the random intercept random slope model (model 2). Lastly, random intercept and random slope models with two time-varying predictors (HE and TBH; model 3) and an interaction term between HE and TB (model 4) were created. A separate model that included HE as criterion and TBH as predictor was analysed.

All models were estimated using restricted maximum likelihood (RML). In order to compare the appropriateness of the specified models, AIC, BIC and log-likelihood values were used. Analyses were performed using R software (version 6.3.0; R Core Team 2014 ), the lme4 package (Bates et al. 2015 ) and the psych package (Revelle, 2019 ).

Descriptive Statistics of Sample

Baseline sociodemographic and clinical characteristics of the N = 22 included patients are displayed in Table 2 . The majority of the sample was female and on average 56 years old ( SD = 18.1). Symptom severity ranged from mild to moderately severe levels of depression (6 ≤ PHQ-9 ≤ 20) at the beginning of treatment resulting in a moderately depressed status on average.

Psychometric Properties of GHES and StHAR

With regard to psychometric properties of the scales, corrected item-total correlations ranged from .46 to .78 for GHES and from .39 to .61 for StHAR. Internal consistency of GHES was excellent across treatment (ω = .87), with values ranging from .79 to .91 across sessions. Internal consistency for StHAR was good across treatment (ω = .80) with values ranging from .63 to .87 across sessions. Internal consistency for StH-A was .73 and .68 for StH-R. We calculated ICC using a two-way random effects model (ICC 2,2 ) (Shrout and Fleiss, 1979 ) to estimate IRR. For GHES, ICCs (2,2) across all rater dyads ranged from .41 to .81, resulting in a moderate average ICC (2,2) of .68 as well as a moderate median ICC (2,2) of .70. For StHAR, ICCs (2,2) across rater dyads ranged between .45 and .83 resulting in a moderate average ICC of .64 and a moderate median IRR of .64. Due to the good psychometric properties of StHAR, the global StHAR score was used instead of the subscales StH-A and StH-R in further analyses.

Descriptive Statistics of Homework, HE, and TBH

Across all telephone sessions and patients, 411 homework activities were assigned in total, resulting in approximately two defined homework tasks per session and per patient on average. The majority of the homework was classified as psychoeducational ( n = 142; 35%) and behavioral ( n = 138; 31%), followed by cognitive ( n = 76; 18%), self-monitoring ( n = 36; 9%), and relapse prevention ( n = 29; 7%) homework. In total, 380 (92.5%) of the homework activities were completed. Across all patients and therapy sessions HE was on average M = 2.71 ( SD = 0.74), which translates into moderate to high HE when using the item anchors. Difficulties in completing homework assignments were reported in 75% of the sessions, with the extent of difficulties showing an average of M = 1.53 ( SD = 1.10). Using the item anchors, this value translates to small to moderate difficulties. Most commonly assessed types of difficulties encountered by patients were negative events that impeded homework completion (34.1%), depressive symptoms (29.7%), and lack of strategies and options to complete homework (13.7%). Lack of time (8.2%), homework being too difficult (8.2%), and other homework-related aspects (6.0%) were further reported difficulties in completing the task. HE and TBH showed a small significant association across sessions, with a mean correlation of r = .28 ( p < .05). Descriptive information on HE and TBH per session are presented in Table 3 .

Course of HE and TBH and Their Association

With regard to variation in HE among patients and across treatment, we first ran an unconditional or null model with HE as criterion. The average HE across patients and treatment is 2.70 ( SE = 0.09). Calculations of ICC using the within- and between-patient variance shows that 25% of the variance in initial status of HE are attributed to differences among patients. Entering time as predictor (model 1), the unconditional growth model demonstrates that patients start on average with high HE ( M = 3.00, SE = 0.13) and show a small reduction in HE during the course of treatment (− 0.05, p = .011). With regard to TBH, 14.8% of variance can be attributed to differences between patients. The initial status of TBH is 2.32 ( SE = 0.13) and shows a similarly small, but statistically non-significant reduction during the course of the treatment (− 0.04, p = .307). The models regarding course of HE and TBH are displayed in Table 4 .

In order to explore the association between HE and TBH, stepwise multilevel models were built with HE as criterion in a separate model. TBH consisting of TBH-A from the previous session and TBH-R from the following session was entered as a time-varying predictor of HE in the subsequent session. TBH was significantly and positively related to HE over the course of treatment (0.24, SE = 0.07, p = .032). Results are displayed in Table 5 .

Association Between HE, TBH, and Depressive Symptoms

For the association between HE, TBH, and depressive symptoms, we first ran an unconditional or null model, which demonstrated a within-patient variability in depressive symptoms of 38% (data not shown), indicating a nested structure of the data. After modelling the time slope (model 1), time-varying predictor 1 was entered at level 1 (model 2). Time-varying predictor 1 was HE of the current session, since ratings refer to the interval between two sessions. Higher scores on HE were associated with lower depressive symptoms over the course of treatment (− 0.83, SD = 0.35, p = .015). Comparison of model 1 and model 2 returned better fit indices for model 2 (log-likelihood for model 1 = - 451.37 and for model 2 = − 448.05, p = .009; AIC for model 1 = 910.74 and for model 2 = 906.10; BIC for model 1 = 923.3 and for model 2 = 921.8;) for the random intercept random slope model with HE as predictor (smaller values indicate better fit). Next, the second time-varying predictor—TBH from the previous session—was introduced into the model at level 1. TBH was not significantly related to depressive symptoms (0.23, SD = 0.30, p = .437). Compared to model 2, model 3 did not show improved model fit (log-likelihood for model 2 = − 444.69 and for model 3 = − 444.24, p = .346; AIC for model 2 = 903.4, and for model 3 = 904.5; BIC for model 2 = 925.4 and for model 3 = 929.6), indicating the model with HE as predictor fits the data better. The last model (model 4) included an interaction between the two time-varying predictors, however the model did not converge. Results of the random intercept model (model 1), the random intercept and random slope model with one predictor (model 2), and the random intercept random slope model with two predictors (model 3) are presented in Table 6 .

The present study describes types and amount of homework assigned and depicts rather high levels of HE in tel-CBT. Results of our study further show that HE decreases slightly throughout the course of therapy and that TBH is related to HE over the course of therapy. Ultimately, results reveal that higher scores on HE are associated with lower levels of depressive symptoms, but that TBH and depressive symptoms are not associated.

The study demonstrates that homework assignments and engagement with homework play a central role in tel-CBT – as could be expected from the guided self-help approach. This is indicated by the overall amount of assigned homework across therapy and patients, the proportion of homework completed by patients, and the patients’ rather high HE throughout the course of the treatment. As expected, we found that homework was overall assigned in most of the therapy sessions. The fact that on average two homework assignments were prepared in each session confirms that contents were employed and implemented as scheduled by tel-CBT. This treatment format lays special emphasis on this kind of intersession activity.

When modelling the status and course of HE and TBH, both variables showed more within-patient variability compared to between-patient variability over the course of the treatment, as indicated by the ICC calculations of variance components and the slopes of the variables in the models. Inter-individual differences explained rather small proportions of the variance (25% in HE, 15% in TBH), which might indicate that both variables are dynamic rather than stable patient characteristics. The overall high HE across patients might be explained by sociodemographic and clinical patient characteristics. The average age of our sample was rather high and the vast majority of patients reported having had previous depressive episodes and psychotherapy experience. It is likely that patients with a history of depression and of undergoing treatment are trying particularly hard to make the most out of therapy. Moreover, older patients might show a sense of self-responsibility when it comes to carrying out therapeutic homework. Contrary to the belief that adult patients may have reservations regarding homework due to their age, there is evidence that adult patients have positive attitudes towards homework, with the vast majority of patients not perceiving themselves too old for homework (Fehm and Mrose 2008 ). HE declined slightly over the course of treatment and visual inspection of the individual courses of HE showed that drops in HE happened in some patients in single sessions. These variations are expected to be due to specific external factors that have an influence on the patient's HE at a given session. For example, further explorative analyses might scrutinize which external factors regarding homework (such as difficulties completing the homework task; lack of resources or time in a given week) and session content might be responsible for situations with a drop in HE. In view of previous suggestions that homework compliance might not be linear across treatment of social anxiety disorder (Leung and Heimberg 1996 ), future studies might employ statistical models that are suitable to detect various patterns of HE. For example, latent growth analysis, which requires much larger samples than the one used in our study, would allow to detect differences in latent factors between groups of patients, and to relate different HE patterns to treatment outcome (Collins and Sayer 2001 ).

Our study provides empirical support for the association between HE and depressive symptoms throughout the course of tel-CBT in mildly to moderately depressed patients. Using MLM with repeated measures of predictors and outcome, we found a medium-sized association between HE shown between sessions and depressive symptoms in the subsequent session. In other words, when HE increases by one unit in an interval of two sessions, patient's symptomatology decreases an average of 0.8 units on the PHQ-9 in the subsequent session. Overall, this result goes in line with meta-analytic evidence of the relation between homework compliance and treatment outcome showing a weighted mean effect size on therapy outcome of r = .22 for homework compliance and r = .36 for the employment of homework in therapy (Kazantzis et al. 2000 ). Moreover, the result corresponds to one previous study focusing on a similar conceptualization of HE, which found an immediate effect of HE on symptom outcome in the subsequent session (Conklin and Strunk 2015 ). In our study, TBH was not associated with depressive symptoms in the subsequent session. However, our results indicate that TBH was significantly related to HE over the course of treatment, which corresponds to results of a previous study that found TBH to significantly predict subsequent HE (Conklin et al. 2018 ). Explanations for these findings could be that some clinically beneficial TBH might have been less present in the overall therapists’ behaviors and therefore exerted an effect on HE but not on depressive symptoms. Even though the homework procedure in our study tended to be therapist-initiated, the patients took an active part in tel-CBT, as the majority of the session time was spent on reviewing patients’ experiences with the previous homework and discussing future homework It needs to be stressed that therapists were not trained in specific assignment and review procedures. This means that some aspects of assigning homework that received clinical and empirical support in previous work, were not implemented in our study. For example, it is recommended to write down homework tasks and instructions (Cox et al. 1988 ) in order to assure higher homework compliance. Moreover, a recent study provides preliminary support for the importance of designing homework tasks that are congruent with what the patient perceived helpful in the session (Jensen et al. 2020 ). Since therapists were instructed to adhere to the homework assignments as scheduled, they were not entirely free to consider whether the homework type scheduled for a specific session was appropriate for the patients’ current problem or situation. It is likely that therapists—despite strictly assigning the activity types as scheduled in the treatment manual—adequately adapted the different homework types to the patient's individual situation and promoted patient's willingness and ability to engage with homework outside the therapy session. Our results further suggest that the specific type of homework might not be the only relevant factor for higher HE, as long as therapists assign and review homework in an elaborate, comprehensible, and convincing manner. Lastly, it is important to consider that the association between TBH and HE might run in the opposite direction in that patients’ higher HE and reporting thereof might have influenced the therapists’ reactions to the patients’ reports.

The present results need to be interpreted in due consideration of several limitations: First, the predictor variables were assessed using two self-constructed rating scales, which have not been validated prior to the study. We did not use standardized or validated instruments to assess HE and TBH, because no process rating instrument targeting the particular conceptualization of these variables exists. We aimed at expanding on the previously reported Homework Engagement Scale (HES) by Conklin and Strunk ( 2015 ) by adding indicators such as intensity of HE or difficulties faced when engaging with homework. Despite good psychometric properties for both scales with regard to internal consistency and moderate to good properties regarding IRR, the validity of GHES might be constrained: Even though GHES is an objective observer-based rating instrument with a precise rating manual, the items do not always allow a direct observation of facets relevant to HE. The appraisal of each item relies on the patient expressing his or her thoughts and experiences with the homework process. However, these narratives might not cover all areas of interest in the rating instrument. For example, the rating on the difficulty-item is indirectly inferred from the narratives of the patient about how engaging with homework went. If the patient did in fact face difficulties affecting HE, but not explicitly mention these when talking about how homework activity went, the measurement of difficulties faced in this situation might not be representative of HE. The rating therefore relates to the raters’ appraisal of whether a patient had faced challenges that might have affected HE, rather than the patients’ subjective feelings or the true influence of experienced difficulties on HE. Objective and observer-based assessments of HE might be supplemented by patients’ reports of difficulties faced as well as by patient ratings on the profoundness with which patients engaged in homework activities as well as the perceived benefits of homework in future research. Second, the StHAR did not specifically target competence or quality of assigning and reviewing homework. Future studies might develop and employ rating instruments that clearly differentiate the extent of TBH shown by the therapist from the competency of these therapeutic actions. Moreover, patient ratings of whether therapists assigned and reviewed the homework in a skilful manner in the patients’ views might add to a better understanding of clinically meaningful TBH.

Third, our methodology and our analytic strategy do not allow for any causal inferences regarding HE and depressive symptoms, despite multiple assessments of HE in session intervals and the depressive symptoms assessed at the beginning of each session. Reverse causation cannot be excluded, since patients might have reported about homework more elaborately and positively in the sessions due to an improved mood. Moreover, depressive symptoms were assessed retrospectively for the time period since the last therapy session. Fourth, the study sample was rather small. Therefore, additional exploratory statistical models for our third research question (e.g., including interaction terms) could not be converged in our models. Lastly, selection bias might have occurred as the majority of the patients self-referred to the overarching clinical trial, potentially leading to the inclusion of generally motivated patients who showed rather small variability in HE and therefore also did not require the therapist to intervene in a way that promotes HE or improves depressive symptoms.

Even though our results should be regarded as preliminary evidence, the findings add to the body of literature due to several strengths. A more comprehensive concept of the extent of homework compliance was used in the present study, going beyond commonly used quantitative measures of homework completion or single-item compliance measures. Several differences between HE and previous operationalizations of homework compliance exist. HE incorporates facets of the quality and the intensity of patient's engagement with the homework tasks, the estimated benefit for the patient of undertaking homework, the estimated transference of acquired skills to the patients’ daily lives, as well as the difficulties experienced by the patient when completing homework. Another strength of the study is the conceptualization of TBH, which incorporates multiple facets regarding preparing and reviewing homework, informed by clinical recommendations. These aspects were derived from listening to and rating complete therapy sessions with high reliability, as indicated by the IRR analyses. Moreover, observer-based ratings of both HE and TBH might provide more objective estimations of HE and discussion of tasks in the therapy session compared to client or therapist reports (Mausbach et al. 2010 ). Lastly, our study provides insight into the course of HE and TBH throughout the entire treatment, which helps generating hypotheses regarding the nature of HE and its relation to TBH and depressive symptoms.

The study provides evidence that homework is implemented by therapists and patients in tel-CBT. Engagement with homework and therapists’ actions to assign and discuss homework varies across treatment in this sample. However, on average a slight decrease of HE throughout the treatment was observed and patients, who show high HE, experience lower depressive symptoms on average. Future studies with designs allowing to determine the direction of causality and with reliable and more economic ways of retrieving information regarding HE in the patients’ natural environments (e.g., using ecological momentary assessment) are warranted. This approach would allow for recording patients’ HE close to occurrence and provide information regarding reasons for low HE as well as facilitators for completing homework without recall bias. TBH was not related to depressive symptoms but showed an association with HE. Future studies might examine whether TBH moderates the HE-symptom improvement relationship and whether specific homework types require specific therapist skills to assign and review in a meaningful way.

Data Availability

The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request.

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Haller, E., Watzke, B. The Role of Homework Engagement, Homework-Related Therapist Behaviors, and Their Association with Depressive Symptoms in Telephone-Based CBT for Depression. Cogn Ther Res 45 , 224–235 (2021). https://doi.org/10.1007/s10608-020-10136-x

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Growing public concern about the role of artificial intelligence in daily life

A growing share of Americans express concern about the role artificial intelligence (AI) is playing in daily life, according to a new Pew Research Center survey.

Pew Research Center conducted this study to understand attitudes about artificial intelligence and its uses. For this analysis, we surveyed 11,201 U.S. adults from July 31 to Aug. 6, 2023.

Everyone who took part in the survey is a member of the Center’s American Trends Panel (ATP), an online survey panel that is recruited through national, random sampling of residential addresses. This way, nearly all U.S. adults have a chance of selection. The survey is weighted to be representative of the U.S. adult population by gender, race, ethnicity, partisan affiliation, education and other categories. Read more about the ATP’s methodology .

Here are the questions used for this analysis , along with responses, and its methodology .

A bar chart showing that concern about artificial intelligence in daily life far outweighs excitement.

Overall, 52% of Americans say they feel more concerned than excited about the increased use of artificial intelligence. Just 10% say they are more excited than concerned, while 36% say they feel an equal mix of these emotions.

The share of Americans who are mostly concerned about AI in daily life is up 14 percentage points since December 2022, when 38% expressed this view.

Concern about AI outweighs excitement across all major demographic groups. Still, there are some notable differences, particularly by age. About six-in-ten adults ages 65 and older (61%) are mostly concerned about the growing use of AI in daily life, while 4% are mostly excited. That gap is much smaller among those ages 18 to 29: 42% are more concerned and 17% are more excited.

Rising awareness, and concern, about AI

A bar chart that shows those who are familiar with artificial intelligence have grown more concerned about its role in daily life.

The rise in concern about AI has taken place alongside growing public awareness. Nine-in-ten adults have heard either a lot (33%) or a little (56%) about artificial intelligence. The share who have heard a lot about AI is up 7 points since December 2022.

Those who have heard a lot about AI are 16 points more likely now than they were in December 2022 to express greater concern than excitement about it. Among this most aware group, concern now outweighs excitement by 47% to 15%. In December, this margin was 31% to 23%.

Similarly, people who have heard a little about AI are 19 points more likely to express concern today than they were in December. A majority now express greater concern than excitement (58%) about AI’s growing role in daily life, while just 8% report the opposite feeling.

Our previous analyses have found that Americans’ concerns about AI include a desire to maintain human control over these technologies , doubts that AI will improve the way things are now, and caution over the pace of AI adoption in fields like health and medicine .

Opinions of whether AI helps or hurts in specific settings

A bar chart that shows Americans have a negative view of AI’s impact on privacy, more positive toward impact in other areas.

Despite growing public concern over the use of artificial intelligence in daily life, opinions about its impact in specific areas are more mixed. There are several uses of AI where the public sees a more positive than negative impact.

For instance, 49% say AI helps more than hurts when people want to find products and services they are interested in online. Just 15% say it mostly hurts when used for this purpose, and 35% aren’t sure.

Other uses of AI where opinions tilt more positive than negative include helping companies make safe cars and trucks and helping people take care of their health.

In contrast, public views of AI’s impact on privacy are much more negative. Overall, 53% of Americans say AI is doing more to hurt than help people keep their personal information private. Only 10% say AI helps more than it hurts, and 37% aren’t sure. Our past research has found majorities of Americans express concern about online privacy generally and a lack of control over their own personal information.

Public views on AI’s impact are still developing, though. Across the eight use cases in the survey, 35% to 49% of Americans say they’re not sure what impact AI is having.

Demographic differences in views of AI’s impact

A bar chart showing that Americans with higher levels of education tend to be more positive about AI’s impact in many areas.

There are significant demographic differences in the perceived impact of AI in specific use cases.

Americans with higher levels of education are more likely than others to say AI is having a positive impact across most uses included in the survey. For example, 46% of college graduates say AI is doing more to help than hurt doctors in providing quality care to patients. Among adults with less education, 32% take this view.

A similar pattern exists with household income, where Americans with higher incomes tend to view AI as more helpful for completing certain tasks.

A big exception to this pattern is views of AI’s impact on privacy. About six-in-ten college graduates (59%) say that AI hurts more than it helps at keeping people’s personal information private. Half of adults with lower levels of education also hold this view.

Men also tend to view AI’s impact in specific areas more positively than women. These differences by education, income and gender are generally consistent with our previous work on artificial intelligence .

Note: Here are the questions used for this analysis , along with responses, and its methodology .

Artificial Intelligence

Alec Tyson is an associate director of research at Pew Research Center

Emma Kikuchi is is a research assistant focusing on science and society research at Pew Research Center

Many Americans think generative AI programs should credit the sources they rely on

Americans’ use of chatgpt is ticking up, but few trust its election information, q&a: how we used large language models to identify guests on popular podcasts, striking findings from 2023, what the data says about americans’ views of artificial intelligence, most popular.

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Published: 24 April 2024

Understanding the matrix: collagen modifications in tumors and their implications for immunotherapy

Rowie Borst 1 , 2 ,
Linde Meyaard 1 , 2 &
M. Ines Pascoal Ramos ORCID: orcid.org/0000-0003-3644-6517 1 , 2 , 3

Journal of Translational Medicine volume 22 , Article number: 382 ( 2024 ) Cite this article

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Tumors are highly complex and heterogenous ecosystems where malignant cells interact with healthy cells and the surrounding extracellular matrix (ECM). Solid tumors contain large ECM deposits that can constitute up to 60% of the tumor mass. This supports the survival and growth of cancerous cells and plays a critical role in the response to immune therapy. There is untapped potential in targeting the ECM and cell-ECM interactions to improve existing immune therapy and explore novel therapeutic strategies. The most abundant proteins in the ECM are the collagen family. There are 28 different collagen subtypes that can undergo several post-translational modifications (PTMs), which alter both their structure and functionality. Here, we review current knowledge on tumor collagen composition and the consequences of collagen PTMs affecting receptor binding, cell migration and tumor stiffness. Furthermore, we discuss how these alterations impact tumor immune responses and how collagen could be targeted to treat cancer.

Introduction

The extracellular matrix (ECM) is a constantly evolving structure that is produced, modified, remodeled and maintained by the cells residing within it. The ECM is dynamic and responds to changes in the local and systemic environment, making it a central player in tissue physiology and pathology such as cancer [ 1 ]. Tissues have unique ECM compositions tailored to their specific mechanical and structural demands which can be further modified in pathological conditions. The main component of the ECM are collagens consisting of 28 different types [ 2 ]. During homeostasis, the biophysical properties of collagen are critical for maintaining tissue integrity. Collagen stiffness is influenced by the size of its fibers; short fibers offer a greater range of orientation possibilities, enhancing tissue permeability, while long fibers align closely, resulting in cells organizing in the same orientation within the tissue [ 3 ]. This close alignment facilitates the formation of collagen crosslinks contributing to increased ECM stiffness [ 4 ]. In the context of tissue repair, additional collagen crosslinks serve as a protective mechanism to aid wound closure.

Cancer is viewed as a form of excessive wound-healing as similar pathways are activated in wound healing and tumorigenesis [ 5 ]. For instance, dense ECM that forms part of the scar tissue in wound healing is similar to collagen deposits known as desmoplasia in cancer, which correlate with poor prognosis [ 5 , 6 ]. During tumor development, desmoplasia is induced by cancer-associated fibroblasts (CAF), macrophages and tumor cells and the produced collagen is resistant to enzymatic degradation [ 7 , 8 , 9 , 10 , 11 ]. CAFs are the main players in collagen remodeling in cancer. These are highly activated fibroblasts and which, in contrast to normal activated fibroblasts after tissue repair, do not undergo apoptosis or return to resting state [ 12 ]. CAFs are a heterogeneous population of cells implicated in different stages of tumor development, from primary growth to metastasis, in different tumor types [ 11 , 12 ]. However, a number of studies propose an anti-tumor role for CAFs, as ablation of CAFs results in more aggressive phenotypes [ 13 ].

A hallmark of cancer is the epithelial-to-mesenchymal transition (EMT). Epithelial cells and endothelial cells secrete a laminin-rich ECM while mesenchymal cells secrete a collagen-rich ECM [ 14 , 15 ]. Both EMT and desmoplasia enhance tumor stiffness by increasing the mechanical strength, density and crosslinking of collagen [ 16 , 17 ]. Cells sense the mechanical properties of their surroundings and in stiffer matrices, pathways promoting proliferation, survival and invasiveness of tumor cells are triggered.

The ECM also influences the migration of immune cells that promote or prevent tumor growth, depending on tumor type and disease stage [ 7 , 9 , 18 , 19 ]. T-cell migration is reduced in dense, stiff matrices compared to less dense, more flexible matrices. T cells preferentially migrate along long collagen fibers using integrin-independent migration while in disorganized collagen structures they use integrin-dependent migration [ 20 ]. Solid tumors can be classified into inflamed “hot” tumors and non-inflamed “cold” (Fig. 1 ). Immune inflamed tumors have a high infiltration of cytotoxic T-cells and in general are responsive to immunotherapy. Non-inflamed tumors are characterized by an absence or low numbers of infiltrated T-cells, increased collagen deposition and the presence of a stromal barrier, abnormal vasculature, lack of chemokines, hypoxia or activated oncogenic pathways [ 21 , 22 , 23 , 24 ]. Non-inflamed tumors have increased resistance to immunotherapy and a higher chance of disease recurrence within five years [ 24 ]. The mechanism behind the resistance is not fully understood but there is an increasing interest in the role of the ECM in immune cell infiltration of tumors. For example, the ability of T-cells to reach the tumor core of lung and ovarian tumors is hindered by the collagen alignment in the tumor periphery [ 25 ].

Inflamed (left) and non-inflamed tumors respond differently to immune checkpoint blockade therapy. Inflamed tumors contain more T cells, antigen presenting cells and inflammatory M1 macrophages compared to non-inflamed tumors. In non-inflamed tumors, T cells are mainly present at the tumor border and have difficulties infiltrating into the tumor. These are also characterized by more tumor-suppressing immune cells such as M2-macrophages and T-regulatory cells and high abundance of collagen produced by fibroblasts and cancer-associated fibroblasts

Collagen expression differs between different cancer types but in general tumors maintain the collagen lineament of the tissue of origin [ 26 ].However, collagens can undergo extensive post-translational modifications (PTM) [ 27 ], which can result in an almost infinite array of matrices. Manipulation of specific PTMs could provide new therapeutic possibilities to inhibit or correct localized pathological alterations to the ECM that occur in cancer or tissue fibrosis. Here, we review current knowledge on the impact of collagen and collagen PTMs on the antitumor response and their potential as therapeutic target.

Collagen-receptor interactions affect tumor growth and anti-tumor immune responses

Cells can interact with collagens through at least six different groups of receptors, namely: (1) integrins, (2) the Discoidin Domain Receptor family (DDR1 and DDR2), (3) the mannose receptor family (4) Glycoprotein VI (GPVI) (5) Osteoclast-associated receptor (OSCAR), (6) Leukocyte Associated Immunoglobulin Like Receptor 1 (LAIR-1) [ 28 ]. The interaction of collagen with these receptors regulates diverse responses, encompassing cell adhesion, matrix metalloprotease (MMP) activity, thrombus formation, cell survival and proliferation, cytokine production, immune effector function and collagen remodeling. (Table 1 ).

Both immune and tumor cells bind to collagens via integrins such as α1β1, α2β1, α3β1, α4β1, α10β1, and α11β1 for migration [ 29 , 35 , 36 ]. Integrins expressed by tumors interact with collagen and overcomes tumor dormancy by increasing tumor cell motility. In contrast, collagen-integrin interaction on immune cells is anti-tumorigenic and promotes migration of T-cells and natural killer cells into the tumor [ 37 ]. Integrin a3 (itga3) mRNA expression is increased by PDAC tumor cells and negatively correlates with T-cell presence which is associated with poor prognosis [ 38 ].

The DDR family consists of receptor tyrosine kinases that bind to collagen and induce MMP secretion and regulate cellular functions [ 30 ]. DDR1 expression is positively correlated with tumor stage and promotes tumor cell proliferation, migration and invasion [ 39 , 40 ]. In PDAC, the DDR1–NF-κB–p62–NRF2 cascade can be activated by cleaved collagen I which limits metabolism and growth of tumours [ 41 ]. In contrast, cleavage resistant collagen I induces proteasomal degradation of DDR1. Binding of DDR1-ectodomain to collagen mechanistically aligns collagen fibers, independent of receptor activation [ 42 ]. Tight fiber alignment can prevent immune cells from infiltrating into the tumor in breast cancer. DDR2 is overexpressed on CAFs and regulates force-mediated collagen fiber remodeling that results in a stiffer tumor microenvironment [ 43 , 44 ].

The uPAR-associated protein (uPARAP/Endo180, encoded by MRC2 ) is an endocytic transmembrane receptor for collagen of the mannose receptor family [ 31 ]. uPARAP facilitates the degradation of collagen and therefore plays a crucial role in ECM homeostasis, tissue remodeling, and turnover. Macrophages and fibroblasts remodel collagens via uPARAP by targeting them to lysosomal degradation. Lower expression of uPARAP/Endo180 in metastatic melanoma and advanced urothelial cancer results in increased responsiveness to immune checkpoint blockade therapy [ 45 ].

Both GPVI and LAIR-1 recognize Glycine-Proline-Hydroxyproline motif repeats in collagens but have opposing effects on immune activation. GPVI signals through an immunoreceptor tyrosine-based activation motif (ITAM) to activate platelets resulting in thrombus formation [ 32 ]. Platelets can interact with tumor cells shielding them from shear stress in the circulation and preventing recognition by natural killer cells [ 46 , 47 ]. In contrast, LAIR-1 is an immune inhibitory receptor that signals through an immunoreceptor tyrosine-based inhibition motif (ITIM) and is broadly expressed on immune cells, including T cells [ 34 , 48 ]. Collagens can set a threshold for immune cell activation through LAIR-1. Collagen deposition in tumors could therefore protect tumor cells from the immune system through LAIR-1 [ 49 ].

Changes in collagen composition during tumor progression

Collagens form a diverse family of proteins with multiple subtypes, each of which has its specific structural and functional characteristics (Table 2 ). The general structure of collagens consists of three polypeptide α-chains that fold into a triple helix, improving the thermal stability of the collagen. The human genome encodes for 44 different forms of α-chains to produce a total of 28 types of collagens [ 50 ]. Depending on the collagen type, this triple-helix is a homotrimer or mixture of two or three different α-chains [ 51 ]. The most common motif within α-chains is a (Gly-X-Y)n-repeat in which every third amino acid is a glycine followed by two non-glycines. The small size of glycine is crucial for the folding of the triple helix. While X–Y can be all amino acids, they most commonly are proline and hydroxyproline, respectively.

Fibrillar collagens

The classical fibrillar or fibril-forming collagens include collagen I, II, III, V, and XI, with collagen I as the most abundant collagen throughout the body. They form long and highly organized fibrils and are the dominant component of the ECM and important contributors to cancer progression if mutated or exceedingly present [ 10 , 53 ]. Long aligned fibrils provide an easy route for tumor cells to migrate out of the tumor nest while excluding immune cells [ 42 , 54 ]. Pancreatic tumor cells produce unique collagen I homotrimers (a1/a1/a1) instead of the normal collagen I heterotrimers (a1/a2/a1), enhancing resistance to MMP degradation and tumor progression [ 38 ]. Homotrimeric collagen I increases proliferation of tumor cells through DDR1 and signaling through ITGA3 compared to heterotrimeric collagen I [ 38 ]. In mice models, deletion of homotrimeric collagen I or suppression of ITGA3 in tumor cells improved overall survival and tumor T-cell infiltration.

While collagen XI is a minor collagen and preferentially expressed in cartilage in homeostasis, several studies report it to be present in tumors and propose to use it as cancer-biomarker [ 55 ]. In ovarian cancer, increased expression of collagen I and XI is associated with disease progression. In non-small lung cancer, collagen XI expression in the tumor induces a negative feedback loop reducing CAF-mediated collagen remodeling and CAF migration as collagen XI sterically interferes with collagen I- integrin-binding [ 55 ].

In several cancer types, collagen V is over-expressed in non-inflamed tumors compared to inflamed tumors, in metastatic tumors compared to primary tumors and in patients resistant to cytotoxic drugs [ 56 , 57 , 58 , 59 , 60 ]. In contrast to most fibrillar collagens, collagen III plays a role in suppressing rather than promoting the metastatic processes such as adhesion, migration and invasion of tumor cells in a murine breast cancer model [ 61 ]. In human head and neck squamous cell carcinomas, collagen III is the most abundant collagen type in patients with dormant tumors compared to tumors from patients with additional lymph node metastases [ 62 ]. The collagen architecture of dormant tumors is characterized by wavy collagen fibers and low degree of linear organization compared to proliferative tumors [ 62 ].

Basement membrane collagens

Network-forming collagens such as collagen IV, -VIII and -X form open network structures instead of fibers. Collagen IV is an essential part of the basement membrane and upregulated in several types of cancer promoting cell proliferation, migration, and invasion [ 63 ]. Network-collagens also play an important role in mediating platelet interaction with tumor cells and thereby enhance metastasis [ 47 ]. Collagen VIII is normally expressed in vascular smooth muscle cells (SMC) and plays an important role in vascular remodeling. High expression of collagen VIII in tumors is associated with poor prognosis, likely through SMC survival and migration, enhancing angiogenesis [ 64 ]. Lastly, expression of collagen X is high in immune-excluded triple-negative breast cancers that are resistant to anti- programmed cell death-1 (PD-1) ICB therapy [ 60 ].

Minor collagens

Although minor collagens are less abundant in human body, they do play a crucial role in collagen structures. Beaded-filament-forming collagens such as collagen VI are closely related to basement membrane collagens. Breast cancer adipocytes upregulate collagen VI expression during tumorigenesis [ 65 , 66 ]. Collagen VI is also found near vascular structures and increased in colorectal cancer [ 67 ].

Anchoring such as collagen VII and Transmembrane collagens such as XIII and XVII have a role in spatial compartmentalization and enhancing cell–cell and cell–matrix interaction, respectively [ 2 , 68 , 69 , 70 ]. In breast cancer, collagen XIII activates the Tumor Growth Factor-β (TGF-β) pathway through B1 integrin, promoting cancer progression and metastasis [ 71 ]. In epithelial cancers, overexpression and increased ectodomain shedding of the transmembrane collagen XVII leads to tumorigenesis and is associated with poor prognosis [ 72 ]. Fibril-associated Collagens with Interrupted Triple Helices (FACIT) are important mediators in the organization of the collagen fibrils and the density of the ECM. In breast cancer FACIT collagens are highly present and inhibit fibril fusion [ 73 , 74 ].

Collagen post-translational modifications and their impact on the anti-tumor immune response

During collagen biosynthesis, the collagen structure undergoes several PTMs. PTMs can modify protein function by altering protein structure, protein–protein interactions, and degradation. PTMs take place intra- and extracellularly and once collagen is in its triple helical form, further PTMs such as hydroxylation and glycosylation will not occur [ 75 , 76 ] (Fig. 2 ).

Schematic overview of collagen post-translational modifications. Hydroxylation of proline and lysine takes place in the endoplasmic reticulum while N-linked glycosylation and O-linked glycosylation of hydroxylysine take place in the endoplasmic Reticulum and golgi apparatus, respectively. The collagen triple helix is formed intracellularly and in most subtypes of collagen N- and C-propeptides are cleaved off after secretion before the collagen can be crosslinked to form collagen fibers. Collagen can also be modified by citrullination or phosphorylation. During collagen remodeling, collagen is normally degraded while in cancer also fragmentation can take place leaving collagen fragments in the circulation [ 2 ]

Proline hydroxylation

The synthesis of fibrillar collagen begins with the formation of procollagen in the endoplasmic reticulum followed by proline and lysine hydroxylation and glycosylation [ 77 ]. Proline hydroxylation on fibrillar collagen by prolyl-4-hydroxylases (P4HA1, P4HA2 and P4HB) is the most frequent PTM and improves stability of the collagen triple helix by forming strong electronegative bonds. Despite the commonality of proline hydroxylation, each collagen helix exhibits a distinctive hydroxylation pattern [ 78 ]. This variability in hydroxyproline localization within the collagen structure impacts protein folding and triple helical configuration and affects protease access to the collagen structure [ 79 , 80 , 81 ]. Hydroxylated proline sites are important for cells to bind and interact with collagen via integrins and DDR receptors. Hence, changes in hydroxylated proline sites impact adhesion, proliferation, and cell migration [ 82 ]. Hydroxyproline and P4HA1 stabilize Hypoxia-inducible factor 1-alpha (HIF-α) enhancing the hypoxia cycle, proline synthesis and collagen deposition [ 83 , 84 ] (Table 3 ). In The Cancer Genome Atlas (TCGA) database, high frequency of mutations in P4HA1 are associated with lower progression free survival [ 85 ]. P4HB is overexpressed in bladder and colon cancer, increasing cell proliferation, migration and reducing apoptosis and in hepatocellular carcinoma inducing EMT [ 86 ]. For healthy collagen IV it is important to undergo PTMs such as 3-proline hydroxylation as the absence of this modification leads to platelet aggregation, which supports tumors [ 63 ].

Loss of P3H2 expression is found in breast cancer and enhances cell proliferation and is therefore pro-tumorigenic [ 87 ]. Taken together, a pattern of increased hydroxylation by prolyl-4-hydroxylases but decreased hydroxylation of 3-proline enhances tumorigenesis. This suggests that specific prolines within the collagen structure may be more susceptible to hydroxylation under pathological conditions, supporting that post-translational changes to collagen structure by specific enzymes could be used as biomarkers [ 82 ].

Lysine hydroxylation

Besides proline, lysine also undergoes hydroxylation which stabilizes collagen triple helixes, increases the stiffness and reduces the sensitivity of collagen to proteases [ 88 , 89 ]. Hydroxylation of lysine is catalyzed by lysyl hydroxylase (LH) and most commonly occurs at lysine residues in the Y-position of the Gly-X-Y sequence repeat. The α2-chains have a higher content of this repeat compared to the α1-chains resulting in more hydroxylated lysine in heterotrimeric collagens compared to homotrimeric collagens [ 76 , 90 ]. Whether a lysine is hydroxylated in collagen depends on the specific amino acid sequence, activity of the hydroxylation enzyme in the collagen-producing cells and/or the collagen conformation during its exposure to the enzyme. For example, hydroxylation by LH3 is especially important in collagen IV as LH3 deficient cell lines accumulate intracellular collagen IV, have reduced secretion and form instable triple helices [ 91 ]. Increased hydroxylation of lysine residues within telopeptides by LH2 is associated with fibrotic conditions by increasing collagen crosslinking and stiffness, protecting the collagen from degradation [ 89 ] (Table 3 ). This supports tumor cells by serving as a physical barrier for therapeutics and promoting metastasis [ 88 , 89 , 92 ]. In contrast, hypoxia decreases hydroxylation of lysine residues [ 78 , 93 ]. In some tumors, mutations in human LH2 (D689A) lead to loss of LH activity reduction of tumor cell migration [ 94 , 95 ].

Glycosylation and glycation

Glycosylation and glycation are enzymatic and non-enzymatic reactions, respectively, of glucose, glucose metabolites and other reducing sugars with different substrates, such as proteins, lipids, and nucleic acids. Similar to other modifications, there is high variability in glycosylation patterns between different types of collagen [ 90 ]. Glycosylation is most common in less organized collagens such as collagen IV. N-linked glycosylation takes place in the endoplasmic reticulum by Collagen Beta(1-O)Galactosyltransferases. For O-glycosylation of collagens there are two glycosyltransferases that catalyze this process: hydroxylysyl galactosyltransferase (GT) and galactosylhydroxylysyl glucosyltransferase (GGT) [ 75 ]. These enzymes add glucose and galactose to the -OH group of hydroxylysine in the Golgi apparatus. The glycosylation of hydroxylysine is crucial in collagen IV and VI to assemble basement membrane. Defects in LH3 prevents intracellular tetramerization of collagen VI and its secretion [ 90 ]. Non-enzymatic glycation can also occur on fibrillar collagens, resulting in a lower number of crosslinks and reduced collagen stiffness [ 35 ]. Adding sugar molecules to collagen fibrils also impacts theirs functionality as it prohibits cell adhesion by blocking integrin-binding places on the structure [ 35 ]. Although tumor cells carry many mutations, documented mutations of genes encoding glycosyltransferases are relatively rare in tumor cells highlighting their importance for collagen stability. Overall, further mechanistic investigation is required to understand the role of collagen glycosylation in cancer and assess its potential as a novel therapeutic target.

Propeptide cleavage

After the procollagen is released to the extracellular space, the N- and C-propeptides of fibrillar collagens are cleaved off. Cleaving of the C-propeptides of collagen I by bone morphogenetic protein 1 (BMP1) impacts the fibril formation and thus the orientation of the collagen structures. Mutations in BMP1 are documented in individuals with gastroschisis and osteogenesis imperfecta and might potentially function as a therapeutic biomarker for individuals with cancer [ 96 , 97 , 98 , 99 ]. However, in case of collagen IV only the N-propeptides are cleaved off. The C-propeptides in the molecules bind head-to-head to form a network, with covalent intra- and intermolecular cross-linking into the subtype structure [ 77 , 100 ]. The cleaved off N-propeptide is a non-collagenous fragment that is also known as arresten which acts as angiogenesis inhibitor [ 101 , 102 ]. Arresten inhibits endothelial cell proliferation, migration and tube formation and reduces subcutaneous tumor growth in mice and suppresses squamous cell carcinoma invasion [ 101 , 102 , 103 ].

Crosslinking affects matrix stiffness

Important enzymes in the regulation of fibril collagen are lysyl oxidase (LOXs) and lysyl oxidase-like (LOXL) that catalyze oxidation of lysine and hydroxylysine in a copper-dependent way [ 100 , 104 , 105 ]. LOX can only catalyze lysine after removal of the C-propeptides which prevents collagen from becoming anionic. High concentrations of copper ions in tumors promote LOX secretion [ 104 ]. The hypoxic TME increases tumor cell expression of LOX and promotes collagen covalent crosslinking, which increases matrix stiffness [ 20 , 106 , 107 , 108 , 109 ] (Table 3 ). LOXL2 suppression in lung tumors mice, increases cytotoxic T-cell infiltration and decreases cytotoxic T-cell exhaustion [ 22 ].

Mutations in LOX are associated with colon tumor pathogenesis [ 110 ]. Despite the wealth of information available on the overexpression of LOXL2 in tumors, there are scarce data regarding the presence of genetic mutations in LOXL2 . Mutations in LOXL2 are identified in skin cutaneous melanoma and uterine corpus endometrial carcinoma. However, LOXL2 mutational burden does not impact the fitness of human tumors, although it is possible that specific mutations could be important in specific types of tumors [ 111 ].

Citrullination and receptor binding

Citrullination changes an arginine residue into a citrulline residue, which is a none-standard amino acid [ 112 ]. Intracellular protein arginine deiminases (PADs) catalyse this process and typically become active when calcium levels exceed the normal physiological concentration, for instance during apoptosis [ 112 ]. Transitioning arginines to citrullines, the reduces the positive charge of the collagen molecule, increasing hydrophobicity. PAD4 citrullinates collagen and is increasingly expressed in several types of cancer, particularly in metastases [ 112 , 113 ]. PAD4 is mainly produced by neutrophils and deletion of this enzyme in mouse tumor models, results in lower neutrophil infiltration in tumors and reduced tumor progression [ 114 ]. In Rheumatoid arthritis citrullinated collagen can bind LAIR-1 as decoy ligand impairing the immunosuppressive function of LAIR-1 on T cells [ 115 ]. In cancer, impaired LAIR-1 mediated inhibition could lead to inflammation in inappropriate sites, depending on the citrullinated collagen location within the tumor. Additionally, citrullinated collagen decreases integrin-mediated cell adhesion, potentially reducing the capacity of immune cells to migrate into the tumor [ 116 ] (Table 3 ). A genome-wide SNP study showed a significant correlation between cutaneous-basal cell carcinoma risk and mutations in the PAD4/PAD6 locus at 1p36 [ 117 ].

Phosphorylation

Network-forming collagens, short-chains collagens and FACIT collagens such as collagen III, IV, V, VI, XVII XXVII can be phosphorylated [ 118 ]. Phosphorylation of collagen XVII by ecto-CK2 blocks its ectodomain shedding by Tumor necrosis factor alpha (TNF alpha)-converting enzyme (TACE), affecting the adhesion and motility of epithelial cells [ 119 ]. In squamous cell carcinoma, shed collagen XVII is suggested to promote tumor progression and invasion [ 72 ]. Therefore, it is tempting to speculate that collagen phosphorylation has a protective role in epithelial cancers but further research has to be conducted to elucidate this.

MMP degradation and collagen fragments

The ECM undergoes constant remodeling involving collagen cleavage by proteases such as matrix metalloproteases (MMPs), a disintegrin and metalloproteinases (ADAMs) and ADAM with thrombospondin motifs (ADAMTs) [ 120 , 121 ]. These enzymes directly influence the biological characteristics and functions of collagen by uncovering cryptic sites, releasing collagen-bound growth factors and degrading collagen [ 122 ]. Compared to intact collagen fragmented collagens are unstable and therefore more prone to degradation. However, collagen fragments still have a bioactive role by binding to cell surface receptors regulating numerous biological processes in physiological and pathological situations [ 123 , 124 ]. MMP-1, 8 and 13 also known as collagenase 1, 2 and 3 have a pro-tumorigenic role by cleaving fibrillar collagens and enhancing tumor cell motility. MMP-2 and MMP-9 cleavage activates latent TGF- β and produces collagen fragments which in turn induces TGF-β secretion. TGF-β has an inhibitory effect on cell proliferation in early stages of cancer and is also a key factor in fibrosis [ 125 , 126 ]. Collagen I fragments cleaved by MMP1, 2, and 14 activate the DDR-1 receptor enhancing tumor growth in pancreatic cancer, thereby reducing patient survival [ 41 ]. Collagen I fragments cleaved by MMP-1 and MMP-9 have an inhibitory effect on T-cell receptor activation and IFN-y secretion through LAIR-1 signaling [ 127 ].

Large-scale genomic studies have delved into the potential genetic alterations of MMPs across a spectrum of human malignant tumors from diverse origins. These studies have specifically revealed MMP8 as a frequently mutated gene in human melanoma [ 128 ]. Functional analysis of the identified mutations verified that all mutations result in loss-of-function of MMP8, contributing to melanoma progression. These findings conclusively establish MMP8 as a tumor-suppressor gene. Additionally, parallel studies have expanded these observations to other MMP-related metalloproteinases, such as ADAMTS15 that is genetically inactivated in human colorectal cancer [ 129 ].

Collagen post-translational modifications as potential novel therapeutical targets in cancer

Numerous potential treatments, including antibodies and small molecule inhibitors, are currently studied for their ability to target enzymes and PTMs involved in ECM remodeling in tumors (Table 4 ). Targeting intracellular PTMs could inhibit collagen secretion and deposition, reduce stiffness and change the collagen architecture, thereby improving immune cell migration and penetration into the tumor mass. Various rate-limiting steps in collagen deposition were explored, including the targeting of proline hydroxylases. Knocking down P4HA1, P4HA2, and HIF-α reduces collagen deposition in primary breast cancer tumors, consequently preventing metastases [ 130 ]. Additionally, small molecules targeting P4HA1 reduce tumor growth in colorectal cancer models possibly through inhibition of MMP1 [ 131 ]. Aspirin targets P4HA2 by decreasing its gene transcription which results in reduced collagen deposition and tumor growth in hepatocellular carcinoma [ 132 ].

Collagen fibers in tumors are characterized as linear and compact due to the high level of deposition and post-translational crosslinking. This physical restructuring of collagen progressively stiffens the ECM leading to extensive biochemical and biomechanical changes, affecting cell signaling and tumor tissue three-dimensional architecture [ 133 ]. Therefore, targeting collagen crosslinking might be a good anticancer therapeutic strategy. In mice, anti-BMP1.3 treatment reduces expression of collagen I, LOX and TGF-β leading to a reduced overall scar size and improved cardiac function in a model of cardiac fibrosis [ 134 ]. This therapy shows significant potential in preventing fibrosis with minimal adverse effects. Investigating its potential effects on already established fibrotic tumors or in preventing metastases would be of interest. LOX/LOXL inhibitors, specifically LOXL2 inhibitors, are used in cancer and fibrosis to prevent collagen crosslinking [ 135 ]. In mice and clinical studies, LOXL targeting results in low toxicity and adverse effects, but yielded limited clinical benefits [ 135 ]. In preclinical cancer models, inhibiting LOXL2 does result in a reduction in metastasis but not in reduced primary tumor size [ 136 ]. In the clinic, LOXL2 inhibitors are used before surgical intervention to reduce metastasis [ 137 ]. Given that only the crystal structure of LOXL2 is solved, the potential of inhibitors targeting other LOXL enzymes has yet to be explored. Inhibitors of LOX enzymatic activity such as beta-aminopropionitrile (BAPN) were tested in combination with PD-1 treatment in mouse models leading to tumor reduction and increased T-cell infiltration [ 138 ], however the clinical use of BAPN is impeded by concerns regarding toxicities [ 139 ]. Another approach to reduce LOX/LOXL activity is to target copper which is an important cofactor for LOXL functionality [ 140 ]. Inhibiting copper results in anti-angiogenic, anti-fibrotic activities, however, the mechanism of LOXL-regulation by copper is poorly understood [ 141 ]. In preclinical mouse models, treatment with a copper chelator reduces the levels of myeloid-derived suppressor cells and increases CD4 + T-cell infiltration in tumors [ 140 ].

Extensive experimental and clinical data associate MMPs with tumor invasion, neo angiogenesis, and metastasis, positioning MMPs as promising pharmacologic targets for cancer therapy [ 122 ]. Numerous MMP inhibitors demonstrated promise as anti-cancer treatments in pre-clinical studies [ 142 ]. Unfortunately, none of them progressed significantly in clinical trials due to severe adverse effects, including musculoskeletal pain and inflammation [ 143 ]. MMP inhibitors that lacked specificity did not succeed in clinical trials, but current efforts are focused on developing more specific antibodies and inhibitors [ 144 ].

Of note, most inhibitors are still clinically tested in metastatic cancer while it is hypothesized that MMP inhibition would be more effective in early stages of tumor progression [ 144 ]. Since then, the understanding regarding the diversity of MMPs, the intricacy of their mechanisms, and the cross-reactivity of certain inhibitors with the ADAM and ADAMTS families has increased. Endogenous MMP inhibitors such as Thrombospondin-1 (TSP-1) regulate MMP-2 and MMP-9 activity reducing tumor growth in pre-clinical tumor models [ 145 ]. However, the function of TSP-1 in angiogenesis and tumor progression remains disputable in certain cancers and may be organ specific [ 146 ]. While TSP-1 is identified as an inhibitor of both processes, while in others, it is characterized as a stimulator [ 145 , 147 , 148 , 149 , 150 , 151 ]. Additionally, MMPs can modulate the immune system by regulating chemokines and altering their activity [ 152 ]. MMP9 plays a pivotal role in promoting tumorigenesis across various cancer types. Inhibiting MMP9 leads to enhanced chemotaxis through elevated expression of CXCL10, coupled with increased T-cell activation triggered by higher levels of IL12p70 and IL-18 expression [ 153 ]. In preclinical models, the combined administration of anti-MMP9 and anti-PDL1 results in increased intra-tumoral T-cell diversity characterized by larger CD4/CD8 memory and effector cell populations, along with an enhanced Th1 responses [ 153 ].

The increasing body of evidence for PADs in cancer progression [ 154 ] has resulted in a growing interest towards targeting PADs and citrullination as potential therapeutic targets. Tumor cells can produce PAD4 and high PAD4 expression is found in patients’ blood and malignant tumor tissue [ 155 ]. In mice, PAD4 deletion in combination with ICB therapy results in increased presence and activation of CD8 + T cells, reduced tumor growth and lung metastasis compared to ICB treatment only [ 114 ]. Whether this effect is due to PAD4-mediated collagen citrullination has not yet been investigated in tumors.

Another approach to improve cancer treatments based on tumoral ECM characteristics, is using fusion proteins with a collagen binding domain (CBD) carrying bioactive-inhibiting cues, immune chemoattracts or radioactive substances. For example, recombinant protein containing the EGFR binding fragment of cetuximab improved by a CBD resulted in specific targeting to and penetration into squamous carcinoma A431 cell xenografts [ 156 ]. A similar approach was used with CBDs fused to immune checkpoint inhibitor antibodies and to IL-2 [ 157 ]. Both CBD-fused IL2 and CBD-conjugated checkpoint inhibitors showed enhanced antitumor efficacy and reduced associated toxicity compared with their unmodified counterparts in several tumor models. In addition, CBD fusion to IL-12 is described as result in systemic toxicity reduction and synergy with immune checkpoint inhibitor therapy [ 158 ]. This targeting strategy could also leverage collagen PTMs making this approach more tumor specific. Specific ECM components and PTMs are highly expressed in areas of active tumor invasion and thus could be used as targets. This strategy has the potential to augment the efficacy of radiation, chemotherapy, or targeted therapy by concentrating drugs, or antitumor biologics specifically at active tumor sites, thereby reducing their dispersion in healthy tissues [ 159 ].

Conclusion and future perspectives

Immune therapy revolutionized cancer treatment options. However, not every tumor responds well to this treatment, especially tumors with high desmoplasia and low immune cell infiltration are resistant to therapy. Collagen deposition in tumors acts as a physical barrier to therapeutic treatment. This barrier is not only passive, keeping immune cells out, but can also actively protect the tumor cells specially when altered by certain PTMs. To enhance cancer treatment for non-responders, immune therapy could be combined with therapies targeting the ECM of tumors.

To implement ECM targets in future treatment of cancer patients, more studies should focus on when the ECM changes from being tumor suppressive to tumor promoting and which PTMs play an important role in this process. Promoting increased immune cell infiltration through the breakdown of the ECM may also create an opportunity for tumor cells to disseminate throughout the body. Hence, the course of treatment and the tumor stage should be meticulously assessed and determined. Characterizing different types of collagens, PTMs and the abundance of PTM associated enzymes could aid in stratifying patients who may benefit from ICB alone or in combination with ECM targeted therapies. Targeting collagens and collagen-modifying enzymes for oncological purposes is intricate, given the widespread presence of collagen throughout the body. However, understanding the spatial heterogeneity and temporal dynamics of collagen PTMs in different types of solid tumors has the potential to refine the selective targeting of tumor stroma and bolster anti-tumor immune responses.

Availability of data and materials

Not applicable.

Abbreviations

Extracellular matrix

Immune checkpoint blockade

Post-translational modification

Cancer-associated Fibroblasts

Epithelial-to-mesenchymal transition

Discoidin domain receptor

Glycoprotein VI

Osteoclast-associated receptor

Leukocyte Associated Immunoglobulin Like Receptor 1

Matrix metalloproteases

Immunoreceptor tyrosine-based activating motif

Immunoreceptor tyrosine-based inhibiting motif

UPAR-associated protein

Smooth muscle cells

Programmed cell death-1

Transforming growth factor beta

Fibril-associated Collagens with Interrupted Triple Helices

Prolyl-4-hydroxylases

Prolyl-3-hydroxylases

Hypoxia-inducible factor 1-alpha

The cancer genome atlas

Lysyl hydroxylase

Galactosyltransferase

Galactosylhydroxylysyl glucosyltransferase

Bone morphogenic

Lysyl oxidase

Lysyl oxidase-like

Protein arginine deiminases

Tumor necrosis factor alpha

Tumor necrosis factor alpha (TNF alpha)-converting enzyme

A disintegrin and metalloproteinases

A disintegrin and metalloproteinases with thrombospondin motifs

Beta-aminopropionitrile

Thrombospondin-1

Collagen binding domain

Monoclonal antibody

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We thank our colleagues Michiel van der Vlist and Enrique Andres Sastre for their critical feedback on the manuscript.

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Borst, R., Meyaard, L. & Pascoal Ramos, M.I. Understanding the matrix: collagen modifications in tumors and their implications for immunotherapy. J Transl Med 22 , 382 (2024). https://doi.org/10.1186/s12967-024-05199-3

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