Published on 08.06.17 in Vol 4, No 2 (2017): Apr-Jun
Supporting Homework Compliance in Cognitive Behavioural Therapy: Essential Features of Mobile Apps
Cognitive behavioral therapy (CBT) is one of the most effective psychotherapy modalities used to treat depression and anxiety disorders. Homework is an integral component of CBT, but homework compliance in CBT remains problematic in real-life practice. The popularization of the mobile phone with app capabilities (smartphone) presents a unique opportunity to enhance CBT homework compliance; however, there are no guidelines for designing mobile phone apps created for this purpose. Existing literature suggests 6 essential features of an optimal mobile app for maximizing CBT homework compliance: (1) therapy congruency, (2) fostering learning, (3) guiding therapy, (4) connection building, (5) emphasis on completion, and (6) population specificity. We expect that a well-designed mobile app incorporating these features should result in improved homework compliance and better outcomes for its users.
JMIR Ment Health 2017;4(2):e20
Homework Non-Compliance in CBT
Cognitive behavioral therapy (CBT) is an evidence-based psychotherapy that has gained significant acceptance and influence in the treatment of depressive and anxiety disorders and is recommended as a first-line treatment for both of these [, ]. It has also been shown to be as effective as medications in the treatment of a number of psychiatric illnesses [ - ]. Homework is an important component of CBT; in the context of CBT, homework can be defined as “specific, structured, therapeutic activities that are routinely discussed in session, to be completed between sessions” [ ]. Completion of homework assignments was emphasized in the conception of CBT by its creator, Aaron Beck [ ]. Many types of homework are prescribed by CBT practitioners, including symptom logs, self-reflective journals, and specific structured activities like exposure and response prevention for obsessions and compulsions. These can be divided into the following 3 main categories: (1) psychoeducational homework, (2) self-assessment homework, and (3) modality-specific homework. Psychoeducation is an important component in the early stage of therapy. Reading materials are usually provided to educate the client on the symptomatology of the diagnosed illness, its etiology, as well as other treatment-relevant information. Self-assessment strategies, including monitoring one’s mood using thought records, teach the patients to recognize the interconnection between one’s feelings, thoughts, and behaviors [ ]. For example, depressed patients may be asked to identify thinking errors in daily life and document the negative influences these maladaptive thinking patterns can produce on their behaviors. Various psychiatric disorders may require different types of modality-specific homework. For example, exposure to images of spiders is a treatment method specific to arachnophobia, an example of a “specific phobia” in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) [ ]. Homework is strategically created by the therapist to correct and lessen the patient’s psychopathology. The purpose of these exercises is to allow the patients to practice and reinforce the skills learned in therapy sessions in real life.
Homework non-compliance is one of the top cited reasons for therapy failure in CBT  and has remained a persistent problem in the clinical practice. Surveys of practitioners have suggested rates of non-adherence in adult clients of approximately 20% to 50% [ , ] while adherence rates in adolescents have been reported to be approximately 50% [ ]. Many barriers to homework compliance have been identified in the literature; to facilitate discussions, they can be divided into internal and external factors. Internal factors originate from a client’s own psychological environment while external ones are created by external influences. Internal factors that have been identified include lack of motivation to change the situation when experiencing negative feelings, the inability to identify automatic thoughts, disregard for the importance or relevance of the homework, and the need to see immediate results [ - ]. Various external factors have also been identified, including the effort associated with pen-and-paper homework formats, the inconvenience of completing homework because of the amount of time consumed, not understanding of the purpose of the homework, lack of instruction, and failure to anticipate potential difficulties in completing the homework [ - ]. There is strong evidence suggesting that homework compliance is integral to the efficacy of CBT in a variety of psychiatric illnesses. In the treatment of depression with CBT, homework compliance has been correlated with significant clinical improvement and shown to predict decreases in both subjective and objective measures of depressive symptoms [ - ]. Similarly, homework compliance is correlated with short-term and long-term improvement of symptoms in anxiety disorders, including generalized anxiety disorder (GAD), social anxiety disorder (SAD), hoarding, panic disorder, and post-traumatic stress disorder (PTSD) [ , - ]. Fewer studies have been done on homework compliance in other psychiatric conditions, but better homework compliance has been correlated with significant reductions in pathological behaviors in psychotic disorders [ , ], cocaine dependence [ , ], and smoking [ ]. Two meta-analyses further support the notion that greater homework adherence is associated with better treatment outcomes in depression, anxiety-related disorders, and substance use [ , ].
The Utility of Technology in Enhancing CBT Homework
Despite its demonstrated efficacy, access to CBT (as well as other forms of psychotherapy) remains difficult due to the limited number of practicing psychotherapists and the cost of therapy sessions . With the rise of mass-market mobile communication devices such as the iPhone or other kinds of mobile devices with app capabilities (smartphones), new solutions are being sought that will use these devices to provide therapy to patients in a more cost-effective manner. Mobile phones with app capabilities are portable devices that combine features of a cellphone and a hand-held computer with the ability to wirelessly access the Internet. Over time, ownership of mobile phones in North America has grown [ , ] and progressively lower prices have further reduced barriers to their use and ownership [ , ]. As more and more people acquire mobile phones, the acceptance of and the demand for mobile health solutions have been on the rise [ ]. Boschen (2008), in a review predating the popularization of the modern mobile phone, identified the unique features of the mobile telephone that made it a potentially suitable vehicle for adjunctive therapeutic applications: portability, acceptability, low initial cost, low maintenance cost, social penetration and ubiquity, “always on,” “always connected,” programmability, audio and video output, keypad and audio input, user-friendliness, and ease of use [ ]. Over the last decade, modern mobile phones have supplanted the previous generation of mobile telephones; progressive increases in their computing power, ongoing advances in the software that they run and interact with (eg, JAVA, HTML5, etc.), common feature sets across different operating systems such as Google Inc.'s Android or Apple Inc.'s iOS, and adoption of common hardware elements across manufacturers (eg, touch screens, high-resolution cameras, etc) have enabled the development of platform-independent apps for mobile phones, or at least apps on different platforms with comparable functionality (eg, apps written for Apple's HealthKit or the apps written for Microsoft's HealthVault).
The popularization of the smartphone presents a unique opportunity to enhance CBT homework compliance using adjunctive therapeutic applications such that well-designed mobile software may be able to diminish barriers to CBT  by making CBT therapists' work more cost-effective. However, there are no guidelines and no existing research that directly address the design of mobile phone apps for this purpose. Given this gap in the literature, we searched MEDLINE (1946 to April 2015) and PsycINFO (1806 to April 2015) for all articles related to “cognitive behavioral therapy”, “homework”, “mobile applications” and “treatment compliance or adherence”, and reviewed articles related to (1) mobile technologies that address homework completion, (2) essential features of therapy, or (3) barriers to homework completion in CBT. In this article, we propose a collection of essential features for mobile phone-based apps that will optimally support homework compliance in CBT.
A Proposed List of Essential Features for Mobile Apps That Optimally Support CBT Homework Compliance
In order to be effective for patients and acceptable to therapists, an optimal mobile phone app to support CBT homework compliance should conform to the CBT model of homework while addressing barriers to homework compliance. Tompkins (2002) provides a comprehensive guideline on the appropriate ways to provide CBT homework such that homework should be meaningful, relevant to the central goals of therapy, salient to focus of the session, agreeable to both therapist and client, appropriate to sociocultural context, practiced in session to improve skill, doable, begin small, have a clear rationale, include written instructions, and include a backup plan with homework obstacles . In addition, the therapist providing the homework needs to be curious, collaborative, reinforce all pro-homework behavior and successful homework completion, and emphasize completion over outcome [ ]. By combining Tompkins' guidelines with the need to reduce barriers to homework compliance (as described above), we obtained the following list of 6 essential features that should be incorporated into mobile apps to maximize homework compliance: (1) congruency to therapy, (2) fostering learning, (3) guiding therapy, (4) building connections, (5) emphasizing completion, and (6) population specificity.
Congruency to Therapy
Any intervention in therapy needs to be relevant to the central goals of the therapy and salient to the focus of the therapeutic session. A mobile app is no exception; apps have to deliver useful content and be congruent to the therapy being delivered. There are different types of homework in CBT, including (1) psychoeducational homework; (2) self-assessment homework; and (3) modality-specific homework. Which types are assigned will depend on the nature of the illness being treated, the stage of treatment, and the specific target . An effective app supporting homework compliance will need to be able to adjust its focus as the therapy progresses. Self-monitoring and psychoeducation are major components in the early stage of therapy. Thought records can be used in depression and anxiety while other disorders may require more specific tasks, such as initiating conversation with strangers in the treatment of SAD. Therefore, the treatment modules delivered via mobile phones should meet the specific needs of therapy at each stage of therapy, while also providing psychoeducation resources and self-monitoring capabilities.
While there are large amounts of health-related information on the Internet, the majority of information is not easily accessible to the users . Mobile apps can enhance psychoeducation by delivering clear and concise psychoeducational information linked to the topics being covered in therapy. As psychoeducation is seen as a major component of mobile intervention [ ], it has been incorporated into several mobile apps, some of which have been shown to be efficacious in treating various psychiatric conditions, including stress [ ], anxiety and depression [ ], eating disorders [ ], PTSD [ ], and obsessive compulsive disorder (OCD) [ ]. For example, Mayo Clinic Anxiety Coach is a mobile phone app “designed to deliver CBT for anxiety disorders, including OCD” [ ]. The app contains a psychoeducational module that teaches the user on “the use of the application, the cognitive-behavioral conceptualization of anxiety, descriptions of each anxiety disorder, explanations of CBT, and guidance for assessing other forms of treatment” [ ]. The benefits of delivering psychoeducation via a mobile phone app are obvious: the psychoeducational information becomes portable and is easily accessed by the patient. Furthermore, the information is also curated and validated by proper healthcare authorities, which builds trust and reduces the potential for misinformation that can result from patient-directed Internet searches. However, psychoeducation on its own is not optimal. Mobile interventions that also incorporate symptom-tracking and self-help interventions have resulted in greater improvement when used for depression and anxiety symptoms than those that deliver only online psychoeducation [ ].
In contrast to conventional, paper-based homework, mobile apps can support in-the-moment self-assessments by prompting the user to record self-report data about the user’s current state . While information collected retrospectively using paper records can be adversely affected by recall biases [ ], mobile apps enable the patient to document his or her thoughts and feelings as they occur, resulting in increased accuracy of the data [ ]. Such self-assessment features are found in many mobile apps that have been shown to significantly improve symptoms in chronic pain [ , ], eating disorders [ ], GAD [ ], and OCD [ ]. Continuing with the previous example, the Mayo Clinic Anxiety Coach offers a self-assessment module that “measures the frequency of anxiety symptoms” with a self-report Likert-type scale [ ]. The app tracks users’ progress over time based on the self-assessment data; users reported liking the record of daily symptom severity scores that the application provides.
Evidence suggests that a variety of modality-specific homework assignments on mobile apps are effective, including relaxation practices, cognitive therapy, imaginal exposure in GAD and PTSD [, ], multimedia solutions for skill learning and problem solving in children with disruptive behavior or anxiety disorders [ ], relaxation and cognitive therapy in GAD [ ], or self-monitoring via text messages (short message service, SMS) to therapists in bulimia nervosa [ ]. Mayo Clinic Anxiety Coach, for example, has a treatment module for OCD that “guides patients through the use of exposure therapy” [ ]; patients can use this to build their own fear hierarchies according to their unique diagnoses. Users reported liking the app because it contains modality-specific homework that can be tailored to their own needs. Novel formats, such as virtual reality apps to create immersive environments, have been experimented with as a tool for facilitating exposure in the treatment of anxiety disorders with mostly positive feedback [ - ]. Apps that provide elements of biofeedback (such as heart rate monitoring via colorimetry of users' faces using the mobile phone's camera), have recently begun to be deployed. So-called ”serious games,“ (ie, games developed for treatment purposes), are also showing promise in symptom improvement in certain cases [ , , ].
Doing CBT homework properly requires time and effort. As noted above, any sense of inconvenience while doing the homework may hamper a patient’s motivation to complete the homework. While patients may appreciate the importance of doing homework, they often find the length of time spent and the lack of clear instructions discouraging, resulting in poor engagement rates [, ]. Therefore, it makes sense that the tasks should be simple, short in duration to begin with, and include detailed instructions [ ], since homework completion rates have been shown to be correlated with patients’ knowing exactly what to do [ , ]. Many apps incorporate text messaging-based services or personalized feedback to encourage dynamic interactions between the therapist and the client [ ]. However, the types of homework delivered by these apps are fixed. An app that adapts the contents to the user’s progress in learning homework tasks would be more engaging and effective since therapy should be a flexible process by nature. Ideally, the app would monitor and analyze the user’s progress and adjust the homework's content and difficulty level accordingly. While the effectiveness of this type of app has not been studied, a similar app has been described in the literature for treating GAD [ ]. This app, used in conjunction with group CBT, collected regular symptom rating self-reports from patients to track anxiety. Based on patients’ ratings, the app would respond with encouraging comments and invite patients to practice relaxation techniques or prompt the patient to complete specific built-in cognitive therapy modules if their anxiety exceeded a threshold rating. Despite the simple algorithm used to trigger interventions, use of the app with group CBT was found to be superior to group CBT alone.
Therapists have a number of important roles to play in guiding and motivating clients to complete homework. First, the therapist needs to address the rationale of the prescribed homework and work with the client in the development of the treatment plan . Failure to do this has been identified as a barrier to homework compliance. Second, the therapist should allow the patient to practice the homework tasks during the therapy sessions [ ] in order to build confidence and minimize internal barriers, such as the failing to identify automatic thoughts. Lastly, the therapist has to be collaborative, regularly reviewing homework progress and troubleshooting with the patients [ , ]; this can be done during or in between homework assignments, either in-person or remotely (ie, via voice or text messaging) [ , ].
Reviewing and troubleshooting homework has been seen as a natural opportunity for apps to augment the role of therapists. Individualized guidance and feedback on homework is found in many Internet-based or mobile apps that have been shown to be effective in treating conditions such as PTSD , OCD [ ], chronic pain [ , ], depression and suicide ideation [ ], and situational stress [ ]. Moreover, providing a rationale for homework, ensuring understanding of homework tasks, reviewing homework, and troubleshooting with a therapist have each individually been identified as predictors of homework compliance in CBT [ , ]. However, despite incorporating a variety of features including self-monitoring, psychoeducation, scheduled reminders, and graphical feedback [ ], automated apps with minimal therapist guidance have demonstrated elevated homework non-completion rates of up to 40%, which is less than ideal.
The effects of technology should not interfere with but rather encourage a patient’s ability to build meaningful connections with others . The therapeutic alliance between the therapist and the client is the strongest predictor of therapeutic outcome [ ] and has been suggested to predict level of homework compliance as well [ ]. While there is no evidence so far to suggest that technology-based interventions have an adverse effect on the therapeutic alliance [ , ], this conclusion should not be generalized to novel technologies as their impact on therapeutic alliance has not been well studied [ ].
An arguably more significant innovation attributable to technology has been its potential to allow patients to form online communities, which have been identified as useful for stigma reduction and constructive peer support systems . Online or virtual communities provide patients with a greater ability to connect with others in similar situations or with similar conditions than would be possible physically. Internet-delivered CBT that includes a moderated discussion forum has been shown to significantly improve depression symptoms [ ]. Furthermore, professional moderation of online communities increases users’ trust of the service [ ]. Therefore, including social platforms and online forums in a mobile app may provide additional advantages over conventional approaches by allowing easier access to social support, fostering collaboration when completing homework, and enabling communication with therapists.
A patient’s need to see immediate symptomatic improvement is an impediment to homework compliance since the perception of slow progress can be discouraging to the user . To address this issue, it is important for both therapists and mobile apps to emphasize homework completion over outcome [ ]. While a therapist can urge the client to finish uncompleted homework during the therapy session to reinforce its importance [ , ], there is little a therapist can do in between therapy sessions to remind clients to complete homework. In contrast, a mobile app can, for example, provide ongoing graphical feedback on progress between sessions to motivate users [ , ], or employ automatic text message reminders, which have been demonstrated to significantly improve treatment adherence in medical illnesses [ ]. These features have previously been incorporated into some technology-based apps for homework adherence when treating stress, depression, anxiety, and PTSD [ , , ] with significant symptom improvement reported in one paper [ ].
Homework apps should, where relevant or useful, explicitly be designed taking into account the specific characteristics of its target audience, including culture, gender, literacy, or educational levels (including learning or cognitive disabilities). One example of how culture-specific design features can be incorporated can be found in Journal to the West, a mobile app for stress management designed for the Chinese international students in the United States, which incorporates cultural features into its game design . In this game, breathing activity is associated with the concept of “Qi” (natural energy) in accordance with Chinese traditions; the name of the game itself references to a famous Chinese novel and the gaming environment features inkwash and watercolor schemes of the East Asian style, making the experience feel more “natural” as reported by the users. A different approach to tailoring design is taken by the computer-based games described by Kiluk et al [ ] that combine CBT techniques and multi-touch interface to teach the concepts of social collaboration and conversation to children with autism spectrum disorders. In these games, the touch screen surface offers simulated activities where children who have difficulties with peer engagement can collaborate to accomplish tasks. Children in this study demonstrated improvement in the ability to provide social solutions and better understanding of the concepts of collaboration. Although the population-specific design is intuitively appealing, the degree to which it can enhance homework compliance has yet to be investigated.
There are several additional issues specific to mobile apps that should be carefully considered when developing mobile apps for homework compliance. Because of screen sizes, input modes, the nature of electronic media, etc, standard CBT homework may need to be translated or modified to convert it into a format optimal for delivery via a mobile phone . The inclusion of text messaging features remains controversial, in part because of concerns about client-therapist boundary issues outside the therapy sessions [ ]. One potential solution is to use automated text messaging services to replace direct communication between the therapist and the client so the therapist can't be bombarded by abusive messages [ , , , ]. Privacy and security issues are also real concerns for the users of technology [ ], although no privacy breaches related to text messaging or data security have been reported in studies on mobile apps so far [ , - ]. Designers of mobile apps should ensure that any sensitive health-related or personal data is stored securely, whether on the mobile device or on a server.
Finally, while this paper focused on “essential” features of apps, this should not be misunderstood as an attempt to itemize all elements necessary for designing a successful piece of software. Good software design depends on many important elements that are beyond the scope of this paper, such as a well-designed user interface  that is cognitively efficient relative to its intended purpose [ ] and which makes effective use of underlying hardware.
The popularization and proliferation of the mobile phone presents a distinct opportunity to enhance the success rate of CBT by addressing the pervasive issue of poor homework compliance. A variety of barriers exist in traditional, paper-based CBT homework that can significantly hamper clients’ motivation to complete homework as directed. The 6 essential features identified in this paper can each potentially enhance homework compliance. Therapy congruency focuses the features of the app on the central goal of therapy and fostering learning eases engagement in therapy by reducing barriers. Apps should help the therapist guide the client through therapy and not hinder the therapeutic process or interfere with patient’s building connections with others. It is crucial that homework completion be emphasized by the app, not just homework attempting. Population-specific issues should also be considered depending on the characteristics of targeted users.
As an example of how this applies in practice, “Mental Health Telemetry-Anxiety Disorders” (MHT-ANX) is a new mobile app developed by the Centre for Mobile Computing in Mental Health at Sunnybrook Health Sciences Centre in Toronto that helps patients monitor their anxiety symptoms using longitudinal self-report. The symptom log is therapy congruent to the practice of CBT since it promotes patients' awareness of their anxiety symptoms and the symptoms’ intensity. The simplicity of the app makes it easy for patients to learn to use, consistent with the need for fostering learning and increasing compliance. The MHT-ANX app was designed to share patient data with their clinicians, helping clinicians guide patients through therapy and more readily engage in discussion about symptom records, thus potentially enhancing the therapeutic relationship. Homework completion is emphasized both by automated text message reminders that the system sends and by questions presented by MHT-ANX that focus on how homework was done. While there are few population-specific design issues obvious at first glance in MHT-ANX, the focus groups conducted as part of our design process highlighted that our target group preferred greater privacy in our app rather than ease of sharing results via social media, and prioritized ease-of-use. While not yet formally assessed, reports from staff and early users suggest that MHT-ANX has been helpful for some patients with promoting homework compliance.
Limitations and Future Challenges
The feature list we have compiled is grounded in current technology; as technology evolves, this list may need to be revised. For example, as artificial intelligence  or emotional sensing [ ] develops further, we would expect that software should be able to dynamically modify its approach to the user in response to users' evolving emotional states.
This paper presents our opinion on this topic, supported by a survey of associated literature. Our original intention was to write a review of the literature on essential features of apps supporting CBT homework compliance, but there was no literature to review. The essential features that are the focus of this article are summaries of key characteristics of mobile apps that are thought to improve homework compliance in CBT, but randomized trials assessing the impact of these apps on homework compliance have not yet been done. We would anticipate synergistic effects when homework-compliance apps are used in CBT (eg, if measures of progress collected from an app were used as feedback during therapy sessions to enhance motivation for doing further CBT work), but the actual impact and efficacy of therapy-oriented mobile apps cannot be predicted without proper investigation.
Conflicts of Interest
- Parikh S, Segal Z, Grigoriadis S, Ravindran A, Kennedy S, Lam R, Canadian Network for MoodAnxiety Treatments (CANMAT). Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults. II. Psychotherapy alone or in combination with antidepressant medication. J Affect Disord 2009 Oct;117 Suppl 1:S15-S25. [CrossRef] [Medline]
- Canadian PA. Clinical practice guidelines. Management of anxiety disorders. Can J Psychiatry 2006 Jul;51(8 Suppl 2):9S-91S. [Medline]
- Thase M, Friedman E, Biggs M, Wisniewski S, Trivedi M, Luther J, et al. Cognitive therapy versus medication in augmentation and switch strategies as second-step treatments: a STAR*D report. Am J Psychiatry 2007 May;164(5):739-752. [CrossRef] [Medline]
- Dannon PN, Gon-Usishkin M, Gelbert A, Lowengrub K, Grunhaus L. Cognitive behavioral group therapy in panic disorder patients: the efficacy of CBGT versus drug treatment. Ann Clin Psychiatry 2004;16(1):41-46. [Medline]
- Barlow DH, Gorman JM, Shear MK, Woods SW. Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: a randomized controlled trial. JAMA 2000 May 17;283(19):2529-2536. [Medline]
- O'Connor K, Todorov C, Robillard S, Borgeat F, Brault M. Cognitive-behaviour therapy and medication in the treatment of obsessive-compulsive disorder: a controlled study. Can J Psychiatry 1999 Feb;44(1):64-71. [CrossRef] [Medline]
- Kazantzis N, Arntz A, Borkovec T, Holmes E, Wade T. Unresolved issues regarding homework assignments in cognitive and behavioural therapies: an expert panel discussion at AACBT. Behav change 2012 Feb 22;27(03):119-129. [CrossRef]
- Beck AT, Rush AJ, Shaw BF, Emery G. Cognitive Therapy of Depression. New York: Guilford Press; 1979.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Washington, DC: American Psychiatric Assoc Pub; 2013.
- Helbig S, Fehm L. Problems with homework in CBT: rare exception or rather frequent? Behav Cognit Psychother 1999;32(3):291-301. [CrossRef]
- Kazantzis N, Lampropoulos GK, Deane FP. A national survey of practicing psychologists' use and attitudes toward homework in psychotherapy. J Consult Clin Psychol 2005 Aug;73(4):742-748. [CrossRef] [Medline]
- Gaynor S, Lawrence PS, Nelson-Gray RO. Measuring homework compliance in cognitive-behavioral therapy for adolescent depression: review, preliminary findings, and implications for theory and practice. Behav Modif 2006 Sep;30(5):647-672. [CrossRef] [Medline]
- Leahy R. Improving homework compliance in the treatment of generalized anxiety disorder. J Clin Psychol 2002 May;58(5):499-511. [CrossRef] [Medline]
- Garland A, Scott J. Using homework in therapy for depression. J Clin Psychol 2002 May;58(5):489-498. [CrossRef] [Medline]
- Bru L, Solholm R, Idsoe T. Participants’ experiences of an early cognitive behavioral intervention for adolescents with symptoms of depression. Emot Behav Diff 2013 Mar;18(1):24-43. [CrossRef]
- Williams C, Squires G. The Session Bridging Worksheet: impact on outcomes, homework adherence and participants’ experience. tCBT 2014 Apr 23;7. [CrossRef]
- Rees C, McEvoy P, Nathan PR. Relationship between homework completion and outcome in cognitive behaviour therapy. Cogn Behav Ther 2005;34(4):242-247. [CrossRef] [Medline]
- Simons AD, Marti CN, Rohde P, Lewis CC, Curry J, March J. Does homework “matter” in cognitive behavioral therapy for adolescent depression? J Cogn Psychother 2012 Nov 01;26(4):390-404. [CrossRef]
- Thase M, Callan JA. The role of homework in cognitive behavior therapy of depression. J Psychother Integr 2006;16(2):162-177. [CrossRef]
- Neimeyer R, Kazantzis N, Kassler D, Baker K, Fletcher R. Group cognitive behavioural therapy for depression outcomes predicted by willingness to engage in homework, compliance with homework, and cognitive restructuring skill acquisition. Cogn Behav Ther 2008;37(4):199-215. [CrossRef] [Medline]
- Coon DW, Thompson LW. The relationship between homework compliance and treatment outcomes among older adult outpatients with mild-to-moderate depression. Am J Geriatr Psychiatry 2003;11(1):53-61. [Medline]
- Strunk D, Cooper A, Ryan E, DeRubeis R, Hollon S. The process of change in cognitive therapy for depression when combined with antidepressant medication: Predictors of early intersession symptom gains. J Consult Clin Psychol 2012 Oct;80(5):730-738 [FREE Full text] [CrossRef] [Medline]
- Cowan M, Freedland K, Burg M, Saab P, Youngblood M, Cornell C, et al. Predictors of treatment response for depression and inadequate social support--the ENRICHD randomized clinical trial. Psychother Psychosom 2008;77(1):27-37. [CrossRef] [Medline]
- Hundt N, Amspoker A, Kraus-Schuman C, Cully J, Rhoades H, Kunik M, et al. Predictors of CBT outcome in older adults with GAD. J Anxiety Disord 2014 Dec;28(8):845-850 [FREE Full text] [CrossRef] [Medline]
- Lebeau RT, Davies C, Culver N, Craske M. Homework compliance counts in cognitive-behavioral therapy. Cogn Behav Ther 2013;42(3):171-179. [CrossRef] [Medline]
- Edelman RE, Chambless DL. Adherence during sessions and homework in cognitive-behavioral group treatment of social phobia. Behav Res Ther 1995 Jun;33(5):573-577. [Medline]
- Leung AW, Heimberg RG. Homework compliance, perceptions of control, and outcome of cognitive-behavioral treatment of social phobia. Behav Res Ther 1996;34(5-6):423-432. [Medline]
- Tolin D, Frost R, Steketee G. An open trial of cognitive-behavioral therapy for compulsive hoarding. Behav Res Ther 2007 Jul;45(7):1461-1470 [FREE Full text] [CrossRef] [Medline]
- Westra H, Dozois DJ, Marcus M. Expectancy, homework compliance, and initial change in cognitive-behavioral therapy for anxiety. J Consult Clin Psychol 2007 Jun;75(3):363-373. [CrossRef] [Medline]
- Mueser K, Rosenberg S, Xie H, Jankowski M, Bolton E, Lu W, et al. A randomized controlled trial of cognitive-behavioral treatment for posttraumatic stress disorder in severe mental illness. J Consult Clin Psychol 2008 Apr;76(2):259-271 [FREE Full text] [CrossRef] [Medline]
- Cammin-Nowak S, Helbig-Lang S, Lang T, Gloster A, Fehm L, Gerlach A, et al. Specificity of homework compliance effects on treatment outcome in CBT: evidence from a controlled trial on panic disorder and agoraphobia. J Clin Psychol 2013 Jun;69(6):616-629. [CrossRef] [Medline]
- Glenn D, Golinelli D, Rose R, Roy-Byrne P, Stein M, Sullivan G, et al. Who gets the most out of cognitive behavioral therapy for anxiety disorders? The role of treatment dose and patient engagement. J Consult Clin Psychol 2013 Aug;81(4):639-649 [FREE Full text] [CrossRef] [Medline]
- Dunn H, Morrison A, Bentall RP. Patients' experiences of homework tasks in cognitive behavioural therapy for psychosis: a qualitative analysis. Clin Psychol Psychother 2002 Sep;9(5):361-369. [CrossRef]
- Granholm E, Auslander L, Gottlieb J, McQuaid J, McClure FS. Therapeutic factors contributing to change in cognitive-behavioral group therapy for older persons with schizophrenia. J Contemp Psychother 2006 Mar 17;36(1):31-41. [CrossRef]
- Carroll K, Nich C, Ball S. Practice makes progress? Homework assignments and outcome in treatment of cocaine dependence. J Consult Clin Psychol 2005 Aug;73(4):749-755 [FREE Full text] [CrossRef] [Medline]
- Gonzalez V, Schmitz J, DeLaune KA. The role of homework in cognitive-behavioral therapy for cocaine dependence. J Consult Clin Psychol 2006 Jun;74(3):633-637. [CrossRef] [Medline]
- Funk A, Zvolensky M, Schmidt N. Homework compliance in a brief cognitive-behavioural and pharmacological intervention for smoking. J Smok Cessat 2011 Dec;6(2):99-111. [CrossRef]
- Kazantzis N, Deane F, Ronan K. Homework assignments in cognitive and behavioral therapy: a meta-analysis. Clin Psychol Sci Pract 2000;7(2):189-202. [CrossRef]
- Mausbach B, Moore R, Roesch S, Cardenas V, Patterson T. The relationship between homework compliance and therapy outcomes: an updated meta-analysis. Cognit Ther Res 2010 Oct;34(5):429-438 [FREE Full text] [CrossRef] [Medline]
- Payne KA, Myhr G. Increasing access to cognitive-behavioural therapy (CBT) for the treatment of mental illness in Canada: a research framework and call for action. Healthc Policy 2010 Feb;5(3):e173-e185 [FREE Full text] [Medline]
- Smith A. U.S. Smartphone Use in 2015. Washington, DC: Pew Research Center; Apr 1, 2015.
- Milward J, Day E, Wadsworth E, Strang J, Lynskey M. Mobile phone ownership, usage and readiness to use by patients in drug treatment. Drug Alcohol Depend 2015 Jan 01;146:111-115. [CrossRef] [Medline]
- Quorus Consulting Group. CWTA. 2012 Apr 23. 2012 cell phone consumer attitudes study URL: https://www.cwta.ca/wp-content/uploads/2011/08/CWTA-2012ConsumerAttitudes.pdf [WebCite Cache]
- Boschen M, Casey LM. The use of mobile telephones as adjuncts to cognitive behavioral psychotherapy. Prof Psychol Res Pr 2008;39(5):546-552. [CrossRef]
- Mirani L. Quartz. 2014 Dec 18. $30 smartphones are here—and they’re getting better every day URL: http://qz.com/314285/30-smartphones-are-here-and-theyre-getting-better-every-day/ [accessed 2015-05-24] [WebCite Cache]
- Dorrier J. SingularityHub. 2014 Mar 7. Cheap devices, like Mozilla’s $25 smartphone, to bring more of developing world online URL: http://singularityhub.com/2014/03/07/cheap-devices-like-mozillas-25-smartphone-to-bring-more-of-developing-world-online/ [accessed 2015-05-24] [WebCite Cache]
- Tompkins M. Guidelines for enhancing homework compliance. J Clin Psychol 2002 May;58(5):565-576. [CrossRef] [Medline]
- Kazantzis N, L'Abate L. Handbook of Homework Assignments in Psychotherapy Research, Practice, and Prevention. New York, NY: Springer; 2007.
- Santor D, Bagnell A. Enhancig the effectivencess and sustainability of school-based mental health programs: maximizing program participation, knowledge uptake and ongoing evaluation using Internet-based resources. Adv Sch Ment Health Promot 2011 Dec 22;1(2):17-28. [CrossRef]
- Proudfoot J. The future is in our hands: the role of mobile phones in the prevention and management of mental disorders. Aust N Z J Psychiatry 2013 Feb;47(2):111-113. [CrossRef] [Medline]
- Rose R, Buckey J, Zbozinek T, Motivala S, Glenn D, Cartreine J, et al. A randomized controlled trial of a self-guided, multimedia, stress management and resilience training program. Behav Res Ther 2013 Feb;51(2):106-112. [CrossRef] [Medline]
- Harrison V, Proudfoot J, Wee P, Parker G, Pavlovic D, Manicavasagar V. Mobile mental health: review of the emerging field and proof of concept study. J Ment Health 2011 Dec;20(6):509-524. [CrossRef] [Medline]
- Cardi V, Clarke A, Treasure J. The use of guided self-help incorporating a mobile component in people with eating disorders: a pilot study. Eur Eat Disord Rev 2013 Jul;21(4):315-322. [CrossRef] [Medline]
- Reger G, Hoffman J, Riggs D, Rothbaum B, Ruzek J, Holloway K, et al. The “PE coach” smartphone application: an innovative approach to improving implementation, fidelity, and homework adherence during prolonged exposure. Psychol Serv 2013 Aug;10(3):342-349. [CrossRef] [Medline]
- Whiteside S, Ale C, Vickers Douglas K, Tiede M, Dammann J. Case examples of enhancing pediatric OCD treatment with a smartphone application. Clin Case Stud 2014 Feb;13(1):80-94. [CrossRef]
- Lind C, Boschen M, Morrissey S. Technological advances in psychotherapy: implications for the assessment and treatment of obsessive compulsive disorder. J Anxiety Disord 2013 Jan;27(1):47-55. [CrossRef] [Medline]
- Newman MG, Consoli AJ, Taylor CB. A palmtop computer program for the treatment of generalized anxiety disorder. Behav Modif 1999 Oct;23(4):597-619. [CrossRef] [Medline]
- Parkinson B, Briner RB, Reynolds S, Totterdell P. Time frames for mood: relations between momentary and generalized ratings of affect. Pers Soc Psychol B 1995 Apr;21(4):331-339. [CrossRef]
- Naylor M, Keefe F, Brigidi B, Naud S, Helzer J. Therapeutic interactive voice response for chronic pain reduction and relapse prevention. Pain 2008 Feb;134(3):335-345 [FREE Full text] [CrossRef] [Medline]
- Kristjánsdóttir OB, Fors E, Eide E, Finset A, Stensrud T, van Dulmen S, et al. A smartphone-based intervention with diaries and therapist-feedback to reduce catastrophizing and increase functioning in women with chronic widespread pain: randomized controlled trial. J Med Internet Res 2013 Jan 07;15(1):e5 [FREE Full text] [CrossRef] [Medline]
- Shapiro J, Bauer S, Andrews E, Pisetsky E, Bulik-Sullivan B, Hamer R, et al. Mobile therapy: use of text-messaging in the treatment of bulimia nervosa. Int J Eat Disord 2010 Sep;43(6):513-519. [CrossRef] [Medline]
- Newman M, Przeworski A, Consoli A, Taylor C. A randomized controlled trial of ecological momentary intervention plus brief group therapy for generalized anxiety disorder. Psychotherapy (Chic) 2014 Jun;51(2):198-206 [FREE Full text] [CrossRef] [Medline]
- Jungbluth N, Shirk S. Promoting homework adherence in cognitive-behavioral therapy for adolescent depression. J Clin Child Adolesc Psychol 2013;42(4):545-553 [FREE Full text] [CrossRef] [Medline]
- Weck F, Richtberg S, Esch S, Höfling V, Stangier U. The relationship between therapist competence and homework compliance in maintenance cognitive therapy for recurrent depression: secondary analysis of a randomized trial. Behav Ther 2013 Mar;44(1):162-172. [CrossRef] [Medline]
- Hanson R, Gros K, Davidson T, Barr S, Cohen J, Deblinger E, et al. National trainers' perspectives on challenges to implementation of an empirically-supported mental health treatment. Adm Policy Ment Health 2014 Jul;41(4):522-534 [FREE Full text] [CrossRef] [Medline]
- Taft C, Murphy C, King D, Musser P, DeDeyn J. Process and treatment adherence factors in group cognitive-behavioral therapy for partner violent men. J Consult Clin Psychol 2003 Aug;71(4):812-820. [Medline]
- Dunn H, Morrison A, Bentall R. The relationship between patient suitability, therapeutic alliance, homework compliance and outcome in cognitive therapy for psychosis. Clin Psychol Psychother 2006 May;13(3):145-152. [CrossRef]
- Kiluk B, Serafini K, Frankforter T, Nich C, Carroll KM. Only connect: the working alliance in computer-based cognitive behavioral therapy. Behav Res Ther 2014 Dec;63:139-146 [FREE Full text] [CrossRef] [Medline]
- McGrath PJ, Lingley-Pottie P, Thurston C, MacLean C, Cunningham C, Waschbusch DA, et al. Telephone-based mental health interventions for child disruptive behavior or anxiety disorders: randomized trials and overall analysis. J Am Acad Child Adolesc Psychiatry 2011 Nov;50(11):1162-1172. [CrossRef] [Medline]
- Przeworski A, Newman M. Efficacy and utility of computer-assisted cognitive behavioural therapy for anxiety disorders. Clin Psychol 2006;10(2):43-53. [CrossRef]
- Wiederhold BK, Boyd C, Sulea C, Gaggioli A, Riva G. Marketing analysis of a positive technology app for the self-management of psychological stress. Stud Health Technol Inform 2014;199:83-87. [Medline]
- Repetto C, Gaggioli A, Pallavicini F, Cipresso P, Raspelli S, Riva G. Virtual reality and mobile phones in the treatment of generalized anxiety disorders: a phase-2 clinical trial. Pers Ubiquit Comput 2011 Oct 2;17(2):253-260. [CrossRef]
- Merry S, Stasiak K, Shepherd M, Frampton C, Fleming T, Lucassen MFG. The effectiveness of SPARX, a computerised self help intervention for adolescents seeking help for depression: randomised controlled non-inferiority trial. BMJ 2012 Apr 19;344(apr18 3):e2598-e2598. [CrossRef]
- Bauminger-Zviely N, Eden S, Zancanaro M, Weiss P, Gal E. Increasing social engagement in children with high-functioning autism spectrum disorder using collaborative technologies in the school environment. Autism 2013 May;17(3):317-339. [CrossRef] [Medline]
- Fehm L, Mrose J. Patients' perspective on homework assignments in cognitive-behavioural therapy. Clin Psychol Psychother 2008;15(5):320-328. [CrossRef] [Medline]
- Fehm L, Mrose J. Patients' perspective on homework assignments in cognitive-behavioural therapy. Clin Psychol Psychother 2008;15(5):320-328. [CrossRef] [Medline]
- Marasinghe R, Edirippulige S, Kavanagh D, Smith A, Jiffry MT. Effect of mobile phone-based psychotherapy in suicide prevention: a randomized controlled trial in Sri Lanka. J Telemed Telecare 2012 Apr;18(3):151-155. [CrossRef] [Medline]
- Knaevelsrud C, Maercker A. Long-term effects of an internet-based treatment for posttraumatic stress. Cogn Behav Ther 2010;39(1):72-77. [CrossRef] [Medline]
- Morris M, Kathawala Q, Leen T, Gorenstein E, Guilak F, Labhard M, et al. Mobile therapy: case study evaluations of a cell phone application for emotional self-awareness. J Med Internet Res 2010 Apr 30;12(2):e10 [FREE Full text] [CrossRef] [Medline]
- Vogel P, Launes G, Moen E, Solem S, Hansen B, Håland Å, et al. Videoconference- and cell phone-based cognitive-behavioral therapy of obsessive-compulsive disorder: A case series. J Anxiety Disord 2012;26(1):158-164. [CrossRef]
- Bickmore T, Gruber A, Picard R. Establishing the computer-patient working alliance in automated health behavior change interventions. Patient Educ Couns 2005 Oct;59(1):21-30. [CrossRef] [Medline]
- Parikh SV, Huniewicz P. E-health: an overview of the uses of the Internet, social media, apps, and websites for mood disorders. Curr Opin Psychiatry 2015 Jan;28(1):13-17. [CrossRef] [Medline]
- Dear B, Zou J, Titov N, Lorian C, Johnston L, Spence J, et al. Internet-delivered cognitive behavioural therapy for depression: a feasibility open trial for older adults. Aust N Z J Psychiatry 2013 Feb;47(2):169-176. [CrossRef] [Medline]
- Middlemass J, Davy Z, Cavanagh K, Linehan C, Morgan K, Lawson S, et al. Integrating online communities and social networks with computerised treatment for insomnia: a qualitative study. Br J Gen Pract 2012 Dec;62(605):e840-e850 [FREE Full text] [CrossRef] [Medline]
- Hudson J, Kendall P. Showing you can do it: homework in therapy for children and adolescents with anxiety disorders. J Clin Psychol 2002 May;58(5):525-534. [CrossRef] [Medline]
- Mattila E, Korhonen I, Salminen J, Ahtinen A, Koskinen E, Sarela A, et al. Empowering citizens for well-being and chronic disease management with wellness diary. IEEE Trans Inf Technol Biomed 2010;14(2):456-463. [CrossRef]
- Jones K, Lekhak N, Kaewluang N. Using mobile phones and short message service to deliver self-management interventions for chronic conditions: a meta-review. Worldviews Evid Based Nurs 2014 Apr;11(2):81-88. [CrossRef] [Medline]
- Aguilera A, Muñoz RF. Text messaging as an adjunct to CBT in low-income populations: a usability and feasibility pilot study. Prof Psychol Res Pr 2011 Dec 01;42(6):472-478 [FREE Full text] [CrossRef] [Medline]
- Lee MD, Kang X, Hanrahan N. Addressing cultural contexts in the management of stress via narrative and mobile technology. Stud Health Technol Inform 2014;199:173-177. [Medline]
- Neimark G. Patients and text messaging: a boundary issue. Am J Psychiatry 2009 Nov;166(11):1298-1299. [CrossRef] [Medline]
- Keoleian V, Stalcup S, Polcin D, Brown M, Galloway G. A cognitive behavioral therapy-based text messaging intervention for methamphetamine dependence. J Psychoactive Drugs 2013;45(5):434-442 [FREE Full text] [CrossRef] [Medline]
- Burner E, Menchine M, Kubicek K, Robles M, Arora S. Perceptions of successful cues to action and opportunities to augment behavioral triggers in diabetes self-management: qualitative analysis of a mobile intervention for low-income Latinos with diabetes. J Med Internet Res 2014 Jan 29;16(1):e25 [FREE Full text] [CrossRef] [Medline]
- Gibson K, Cartwright C. Young people's experiences of mobile phone text counselling: balancing connection and control. Child Youth Serv Rev 2014 Aug;43:96-104. [CrossRef]
- Alvarez-Jimenez M, Alcazar-Corcoles M, González-Blanch C, Bendall S, McGorry P, Gleeson J. Online, social media and mobile technologies for psychosis treatment: a systematic review on novel user-led interventions. Schizophr Res 2014 Jun;156(1):96-106. [CrossRef] [Medline]
- Bauer S, Okon E, Meermann R, Kordy H. Technology-enhanced maintenance of treatment gains in eating disorders: efficacy of an intervention delivered via text messaging. J Consult Clin Psychol 2012 Aug;80(4):700-706. [CrossRef] [Medline]
- Kristjánsdóttir Ó, Fors E, Eide E, Finset A, van DS, Wigers S, et al. Written online situational feedback via mobile phone to support self-management of chronic widespread pain: a usability study of a Web-based intervention. BMC Musculoskelet Disord 2011 Feb 25;12:51 [FREE Full text] [CrossRef] [Medline]
- Granholm E, Ben-Zeev D, Link P, Bradshaw K, Holden JL. Mobile Assessment and Treatment for Schizophrenia (MATS): a pilot trial of an interactive text-messaging intervention for medication adherence, socialization, and auditory hallucinations. Schizophr Bull 2012 May;38(3):414-425 [FREE Full text] [CrossRef] [Medline]
- Furber G, Jones G, Healey D, Bidargaddi N. A comparison between phone-based psychotherapy with and without text messaging support in between sessions for crisis patients. J Med Internet Res 2014 Oct 08;16(10):e219 [FREE Full text] [CrossRef] [Medline]
- Norman DA. The Design of Everyday Things. New York, NY: Basic Books; 2013.
- Grunwald T, Corsbie-Massay C. Guidelines for cognitively efficient multimedia learning tools: educational strategies, cognitive load, and interface design. Acad Med 2006 Mar;81(3):213-223. [Medline]
- McCarthy J. What is artificial intelligence?. 2007 Nov 12. URL: http://www-formal.stanford.edu/jmc/whatisai/ [accessed 2016-10-13] [WebCite Cache]
- Zhao M, Adib F, Katabi D. Emotion recognition using wireless signals. 2016 Presented at: Proceedings of the 22nd Annual International Conference on Mobile Computing and Networking; 2016 Oct 3-7; New York City, NY. [CrossRef]
|CBT: cognitive behavioral therapy|
|GAD: generalized anxiety disorder|
|MHT-ANX: Mental Health Telemetry-Anxiety Disorders|
|OCD: obsessive compulsive disorder|
|PTSD: post-traumatic stress disorder|
|SAD: social anxiety disorder|
Edited by O Zhabenko; submitted 27.10.15; peer-reviewed by P Cipresso, E Pedroli; comments to author 25.12.15; revised version received 02.06.16; accepted 15.02.17; published 08.06.17
©Wei Tang, David Kreindler. Originally published in JMIR Mental Health (http://mental.jmir.org), 08.06.2017.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Mental Health, is properly cited. The complete bibliographic information, a link to the original publication on http://mental.jmir.org/, as well as this copyright and license information must be included.