Most of us would assume that the more homework a client practices the greater the reduction in symptoms. The simple reverse of the university experience, the more homework I do the more my grades increase!
Homework has historically been an essential component of many therapies for posttraumatic stress disorder (PTSD) and other mental health conditions. This blog discussed 2018 research supporting the notion that practice reduces symptoms.
More recent research in 2023 and 2025 suggests that homework is more complicated than the simple do more, get better ideal. This blog will examine some of the research in relation to CPT for PTSD and consider the implications for clinical practice.
Homework Completion and Changes in PTSD Symptoms
Research by Shannon Wiltsey Stirman and colleagues published in 2018 examined the relationship between homework completion and changes in PTSD symptoms during treatment. The findings might not be what you expect.
The findings revealed that clients with greater pre-treatment PTSD symptoms were more likely to complete more homework for Session 1. However, PTSD symptoms did not predict homework completion after this.
Additionally, they reported that increased homework completion following Sessions 2 and 3 was linked to less change in PTSD symptoms from Session 2 to Session 4, but greater overall improvement from pre-treatment to post-treatment.
Similarly, completing more homework after Sessions 8 and 9 was associated with larger decreases in PTSD symptoms in subsequent sessions.
They also found that clients with fewer years of education experienced more substantial symptom change when they completed more homework after Sessions 2 and 3.
Importantly, the average amount of homework completed was not significantly related to client characteristics. The characteristics in this study included:
- Age
- Years of Education
- Months Since Rape
- Minority Status
- Pre-Treatment PTSD symptoms
- Pre-Treatment Depression symptoms
Wiltsey Stirman’s research team also reported that in the latter half of treatment, higher engagement with homework corresponded with reduced treatment dropout rates.
Similarly, the type of CPT undertaken by participants, with a written account or without an account, did not influence homework completion and symptom change.
Drop in practice
Stirman and colleagues noted that the frequency of homework completion decreased somewhat during sessions 6 and 7, before increasing after this. The decrease was not correlated with completion of earlier assignments.
They suggested that the drop in completion might be due to two factors. The first factor was that the cognitive work completed during sessions impacted symptom change. Session 6 and 7 are often focussed on Socratic dialogue while introducing the Alternative Thoughts Worksheet. Therefore, the change experienced by participants may be in addition to, or instead of homework completed outside of session.
The second factor put forward by the team was that nature of the homework may also play a role in this pattern of change. Session 6 and 7 is where the Alternative Thoughts Worksheet is introduced. The worksheet combines all other worksheets and their cognitive restructuring components. It may take longer to complete, and participants may have had some difficulty completing it without additional practice and assistance.
Clinical Implications
These findings are not the linear progression we might expect. That is, the idea that more homework, leads to less symptoms, which might lead to more homework. The fluctuation in homework completion, highlights the complexity of therapeutic work. However,
Stirman and colleague’s conclusion, is the best guide for clinical practice, “our findings suggest that completion of homework is associated with clinical improvements, and that encouraging early and frequent homework activities may enhance treatment outcome.” Pg 24
Homework and PTSD – Further Research
Mercedes Woolley and team (2023) investigated a range of factors related to homework. These included the following.
- Number of Written Homework Attempts
- Time Spent on Homework
- Perceived Helpfulness of Homework
- Percentage of Written Homework Completed
- Therapist Competency in Incorporating Homework into Therapy
Therapist Competency in Incorporating Homework into Therapy
This was defined as the therapists’ skill in integrating homework into therapy and included the following:
(a) reviewing and incorporating homework assignments into sessions
(b) including a clear introduction and assignment of new homework
(c) problem-solving around barriers to homework completion
(d) attempts to increase compliance following noncompletion of homework
(e) reassignment of incomplete work
Therapist Homework Competency
Woolley and colleagues found that low levels of therapist homework competency were associated with significantly poorer treatment response when the patient was spending more time on homework. In short, wasted time on homework. Possibly due to not understanding the purpose of the homework.
Perceived Helpfulness
Woolley et al. found that perceived helpfulness of assignments emerged as the only significant predictor of PTSD symptom reduction. They also found that there was no relationship between perceived helpfulness and the three other homework variables; Number of Written Homework Attempts, Time Spent on Homework
Percentage of Written Homework Completed.
Clinical Implications
If patients recognise the value of homework and clearly comprehend their assignments, even minimal effort on these tasks may contribute to progress in recovery.
Clinicians should not assume that completing homework equates to recognizing its value, or the reverse.
Whilst one could conclude from this study that completing homework was actually not a crucial part of therapy for individuals there are other studies that have the found a value in homework. Stirman et al., (2021) reported “patient competence in completing worksheets independently was associated with greater PTSD symptom decline.”
Asking the question, “Was the home practice helpful”, could be a useful routine query.
Similarly, spending time ensuring clients see a value in homework and clearly understand the content of assignments is wise.
Clinical implications as summarised by Woolley and colleagues (2023) highlight what a therapist should do.
“These results support the idea that therapists should personalize the approach to assigning homework. This may include making sure the patient understands the rationale for the assignment and appreciates the role of out-of-session practice, identifying any obstacles to completing homework or frustration the homework might be causing, and titrating the dose of homework to best meet the patient’s individual needs.” Pg 7
Homework – Depression and PTSD
Kristen Walter and colleagues (2025) studied the impact of adherence to practice assignments and their perceived helpfulness on PTSD and depression outcomes among service members with both PTSD and major depressive disorder.
Two treatment groups were compared. Cognitive Processing Therapy (CPT) for PTSD and behavioral activation-enhanced CPT (BA+CPT) for major depressive disorder and PTSD
The team reported participants in BA+CPT adhered more to practice assignments than those in CPT. However, they stated that this was mainly driven by greater adherence to the behavioral activation assignments than to the CPT assignments. They went on to add that those in the CPT condition were more adherent to the CPT assignments than those in BA+CPT group.
Homework and PTSD
Walter and colleagues reported that adherence was not linked to PTSD or depression outcomes. Perceived helpfulness was similar across treatments, but higher perceived helpfulness correlated with greater PTSD improvement and more treatment completion.
Clinical Implications
Walter’s team also suggested that building trust in practice assignments and working together to choose those most relevant for patients are ways to improve treatment results.
How much homework should a client do?
As you can see the research seems to indicate, we should not be asking how much homework did you do? Rather we should ask how helpful was the homework?
Foot notes
Both Walter et al., (2025) and Woolley et al., (2023) raised that further consideration should be given to what helpfulness may represent, for example:
Walter et al., (2025) “Another possibility is that perceived helpfulness may serve as a proxy for other related constructs, such as therapeutic alliance, treatment buy-in, or is a function of symptom reduction”
Woolley et al., (2023) “It is possible patients who value the homework element of the therapy similarly value the entire therapeutic process.”
References
Stirman, S. W., Gutner, C. A., Suvak, M. K., Adler, A., Calloway, A., & Resick, P. (2018). Homework Completion, Patient Characteristics, and Symptom Change in Cognitive Processing Therapy for PTSD. Behavior Therapy, 49(5), 741–755. https://doi.org/10.1016/j.beth.2017.12.001
Stirman, S. W., Gutner, C. A., Gamarra, J., Suvak, M. K., Vogt, D., Johnson, C., Wachen, J. S., Dondanville, K. A., Yarvis, J. S., Mintz, J., Peterson, A. L., Young-McCaughan, S., & Resick, P. A. (2021). A Novel Approach to the Assessment of Fidelity to a Cognitive Behavioral Therapy for PTSD Using Clinical Worksheets: A Proof of Concept With Cognitive Processing Therapy. Behavior Therapy, 52(3), 656–672. https://doi.org/10.1016/j.beth.2020.08.005
Walter, K. H., Otis, N. P., Kline, A. C., Miggantz, E. L., Hunt, W. M., & Glassman, L. H. (2025). Was it helpful? Treatment outcomes and practice assignment adherence and helpfulness among U.S. service members with PTSD and MDD. Cognitive Behaviour Therapy. Advance online publication. PTSDpubs ID: 1646642. https://doi.org/10.1080/16506073.2025.2482155
Woolley, M. G., Smith, B. N., Micol, R. L., Farmer, C. C., & Galovski, T. E. (2023). Evaluating the relative contribution of patient effort and therapist skill in integrating homework into treatment for posttraumatic stress disorder. Psychological Trauma: Theory, Research, Practice, and Policy, No Pagination Specified-No Pagination Specified. https://doi.org/10.1037/tra0001459
