Mediators and Moderators of Homework–Outcome Relations in CBT for Depression: A Study of Engagement, Therapist Skill, and Client Factors

  • Rui Ying YewEmail author
  • Keith S. Dobson
  • Michael Zyphur
  • Nikolaos Kazantzis
Original Article


Homework assignments are considered crucial to the generalization and maintenance of skills and cognitive reappraisal in cognitive behavior therapy (CBT). The present study examined the relationships among homework engagement (i.e., quantity and quality of adherence, taking into account task difficulties and obstacles), the theoretically meaningful determinants of engagement (i.e., client homework beliefs), therapist competence (i.e., in review, design, and planning of homework), and outcome in CBT for depression. Client factors (i.e., education level, marital status, and baseline depressive symptoms) were also examined as moderators of engagement-outcome relations. It was hypothesized that homework engagement would mediate the relationship between competence at one session and depressive symptoms at the next session. It was further hypothesized that homework beliefs would mediate the competence–engagement relationship. Independent observers assessed homework engagement, beliefs, and therapist competence in 50 client-therapist dyads, representing 233 sessions across five time points (sessions 3, 6, 9, 12, and 15). Cross-lagged panel analysis indicated no lagged competence–outcome effects and pooled multilevel analyses revealed no mediating effects of engagement or beliefs. However, higher client homework beliefs (more positive views) significantly predicted greater homework engagement. No evidence was obtained for hypothesized moderators. The present study is the first to examine specific homework beliefs as determinants of engagement. Findings underscore the importance of beliefs in understanding homework engagement, and provide avenues for future research.


Homework Adherence Competence Cognitive behavior therapy Depression 



The authors would like to thank Tara Impala for reviewing an early version of the manuscript.

Author Contributions

All authors contributed to the study conception and design. Data collection was carried out by RYY and several research assistants at the Cognitive Behaviour Therapy Research Unit at Monash University. Data analyses were performed by RYY and MZ, with RYY, MZ and NK being equally responsible for interpretation of the results. RYY and NK had primary responsibility for writing the manuscript, and other authors reviewed, commented on, and edited previous versions of the manuscript. All authors read and approved the final manuscript.

Compliance with Ethical Standards

Conflict of Interest

Dr. Kazantzis reported being a board member of the International Association of Cognitive Therapy, which has a strategic partnership with the Academy of Cognitive Therapy; being a consultant to the Australian Psychological Society Institute; serving on the international advisory committee and receiving personal fees from the Beck Institute for Cognitive Behavior Therapy and Research; receiving compensation from SpringerNature; and receiving royalties from SpringerNature, Guilford, and Routledge. Rui Ying Yew, Keith S. Dobson, and Michael Zyphur declare that they have no conflict of interest.

Ethical Approval

CBT sessions were drawn from a clinical trial conducted at the University of Washington, on which Dr. Dobson was a Principal Investigator. This trial was funded by the National Institute of Mental Health (NIMH Grants 2R01 MH44063-06 and 5K02 MH00868-05), and participants in the trial had given informed consent for their data to be used for research purposes. The Cognitive Behaviour Therapy Research Unit (CBTRU) at Monash University was granted access to these data under a data access agreement with the University of Calgary, and with ethical approval from the La Trobe University and Monash University Human Research Ethics Committees.

Supplementary material

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Supplementary file1 (PDF 630 kb)


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Authors and Affiliations

  1. 1.Cognitive Behavior Therapy Research Unit, School of Psychological Sciences and Turner Institute of Brain and Mental HealthMonash UniversityClaytonAustralia
  2. 2.Department of PsychologyUniversity of CalgaryCalgaryCanada
  3. 3.Department of Management and MarketingUniversity of MelbourneParkvilleAustralia

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