Homework In Psychotherapy

Broder, M. Making Optimal Use Of Homework To Enhance Your Therapeutic Effectiveness. Journal of Rational– Emotive & Cognitive-Behavior Therapy, Volume 17, Number 1, Spring 2000.

MAKING OPTIMAL USE OF HOMEWORK TO ENHANCE YOUR THERAPEUTIC EFFECTIVENESS

Michael S. Broder

ABSTRACT

Homework is a well-established yet extremely under-emphasized aspect of the Rational-Emotive/cognitive behavioral orientation. This article recognizes homework as being a very powerful tool that needs to be incorporated into treatment in order to make it more efficient and effective. The author presents numerous techniques that can be used with virtually any therapeutic approach to maximize the impact of therapy between sessions. They include audio and bibliotherapy, goal setting, SUD Scale, mood management, disputation, affirmations, mood diary, list making, guided imagery, visualization, relaxation and meditation techniques, exposure, and thought stopping techniques. The article concludes with a discussion of why clients display resistance to homework along with some approaches that can be taken to address this resistance.

INTRODUCTION

The use of homework in psychotherapy is a well-established protocol of the Rational-Emotive/Cognitive Behavioral orientation and one of Albert Ellis’ many great contributions to the field. Trademark homework assignments include reading, forms of exposure to an anxious situation, making a decision, and taking a risk such as confronting someone or something more easily avoided (Ellis, 1962; 1996).

Homework empowers our clients to make and see progress on their own. To a great degree, homework can enable your client to become your collaborator in their treatment. Homework can also help you to assess your client’s motivation. After all, if you get an agreement to do a certain type of homework and at the next session it is not done, that can tell you much about a client’s motivation. And one area where most therapists agree is that a client’s level of motivation is one of the greatest predictors of whether treatment will be successful. Yet in most REBT and Cognitive Behavioral literature, homework remains quite underemphasized.

Homework can also be a great focusing tool. But only if it is clear, specific, measurable and doable. “Clear” means that you and your client are on the same page as to what the homework assignment involves; for example, what reading to do or whom to confront. “Specific” means that the homework assignment zeros in on your client’s problem in such a way that its relevancy is obvious to both of you. For example, if you were to assign as homework a relaxation exercise, there would be, hopefully, no question about the relationship between that assignment and the issues you are working on in therapy. “Measurable” means that both you and your client can objectively evaluate the extent to which the assignment was completed so there is no question as to what you mean when you ask if the reading was done or if the list was made. An assignment that is “doable” is one that can be completed by the client. In other words, its outcome depends only on the actions taken by the client and not necessarily on the agreement and! or cooperation of others. An example of a bad homework assignment would be to have the client agree to get a job or to get a date. Instead, you might encourage your client to send out a certain number of resumes or to approach an agreed upon number of people for a date. In these examples of homework, no one else’s agreement is necessary for your client to complete the assignment successfully. On the other hand, getting a job or a date requires the compliance of someone other than the client.

The main premise of homework is a recognition that real changes occur outside your office, not inside your office. In that spirit, I believe that work done by clients between therapy sessions is often as or more important as what is done in the session itself. The main challenge is to make homework as relevant and user-friendly as possible. Homework assignments need to be designed using the principle of successive approximation making sure that the step or steps assigned to be taken are not too large or too small, especially when you are dealing with difficult clients or AXIS II cases.

My personal preference is to have clients spend at least as much time doing homework as they spend in therapy. This is not an absolute or even an optimal amount, but a minimum guideline that I will generally discuss with each client. Another guideline is for you, the therapist, not to work harder than your client. All of us who have done therapy for any length of time know that this can be easier said than done, especially with some of Your more difficult cases. However, this is still a worthy goal.

In this article I offer a smorgasbord of ideas designed to help you do what you do more effectively by making maximum use of the 167 hours in between sessions as well as the therapy hour itself.

Here are a variety of techniques that you can use to engage your clients in between sessions. I will give a flavor for how they can be used as homework assignments with the understanding that they need to be tailored and fine-tuned to suit the Particular needs they are designed to address.

TECHNIQUES THAT CAN BE USED IN BETWEEN SESSIONS

Bibliotherapy and Audiotherapy

Bibliotherapy is assigned reading that is specific to the issue that you are working on in treatment. Few would dispute that the right reading is a great tool; provided, of course, the client does the reading. There are many sources of good and relevant reading information that is available to address virtually any issue (Ellis, 1993). The main problem with bibliotherapy is that clients are not as likely to read as they are to use approaches that require less effort. In addition, different people read and comprehend their reading with considerable variation. Another consideration is that most self-help material is oriented toward women. This is because publishers have long recognized that women out-buy men by a margin of more than four-to-one in the category of bibliotherapy_ type (self, help) materials (Holm, 1998).

One of the best ways to address these bibliotherapy problems is by using audiotherapy or assigning clients to listen to appropriate audiotapes that reinforce the material covered in your session in between sessions_ I have found that audiotherapy is more effective than its bibliotherapy counterpart simply because people are way more likely to listen than to read. If a tape is one-hour long, it will take everyone regardless of his Or her skill level one hour to listen to it_ Also, self-help audiotape publishers. have found that men are as likely some cases more likely) to listen, as are women. In addition, both men and women can listen to audiotherapy assignments while driving cars, exercising or walking, and at other times when they mao the mood to take on one more activity-such as listening not distract them from what they are doing. Proper listening as reading) provides the repetition of information that can h malize the issue(s) they are working on, as well as a reinforce of what is being said and worked on in treatment. When us assigned correctly, audio therapy goes a long way to free the hour so that you may concentrate on resistance and other issue5 more unique to your client.

Repetition is an important aspect of teaching difficult info In my experience, an overwhelming number of clients are more to listen again and again to get that needed repetition than the~ read and reread bibliotherapy material.

For example, if self-evaluation is the issue, they need to learn in the session and by virtue of the homework they are assign whenever they engage in global rating as “I am no good,” an generalization is taking place (Broder, 1995). Then your client disputation and other cognitive restructuring techniques as mo vant.

Clients who are going through major changes need to learn t. and doubt is quite normal, while generally not desirable. Client are working on relationships and sexual issues need to unde~_ that many myths can cause dysfunction. For example, the m in a good relationship orgasms are simultaneous and automatic very dysfunction-causing (Broder, 1996). Where better can a learn that these myths could explain why they may negate sex doing reading or listening to material that makes these points to force what they have learned in their therapy sessions.

Sometimes the easiest part of therapy is communicating info and misinformation about an issue, but at the same time it can one of the most time-consuming parts of treatment. Many thera have trained and supervised over the years have confided that th . tired of going over the same points with client after client after and, therefore, find that they develop a tendency to avoid doing remember the function of biblio- and audio therapy is to give that mation that you the therapist may take for granted, to encourage tition of it, and to reinforce what you are teaching and working the session. Thus, audio- and bibliotherapy can be considered a e ine form of mentoring.

There are several other audiotherapy approaches you can employ.

Many therapists make up relaxation tapes for their clients as well as tapes on other topics. Another fine technique is to encourage your clients to tape their therapy sessions for re-listening. This can be done by bringing their own tape and tape recorder to therapy sessions. They keep the tapes to listen to, perhaps, several times in between sessions. This is a practice that can be quite helpful in getting clients to hear much of the things they “know intellectually” but need to learn on an emotional level. Repetition of this type is one excellent way to achieve a breakthrough with hard-to-integrate material. An often helpful follow-up to this approach is to give your client a short (but expected) “quiz” on things that were said during the previous session, based on the tape they produced in therapy and, hopefully, listened to in between sessions. Finally, there are many audiocassette programs that can be used for audiotherapy purposes. Over the past few years I developed a series of audiotherapy programs that incorporate numerous techniques into a series of self-contained homework assignments with reproducible exercise worksheets which I call The Therapist’s Assistant (Broder, 1995; 1996). This series was edited by Albert Ellis and is one of many resources at your disposal.

Goal Setting

Covering all the steps and ramifications of goal setting and goal prioritizing is often impossible to do within the time constraints of a therapy session. Yet, it is an extremely important step in the therapeutic process. So having your client work on goals-whether or not they were goals established during your session-is a great use of homework time. This includes identifying all the important aspects of the goals-all of the Who, What, When, Where and Why questions. A basic goal-setting homework assignment exercise will have the client come into the next session with answers to all of these questions: What is the goal? What do you want to accomplish by reaching it? Who is it that can be involved in this besides you? That is, who, if anyone, can help you achieve it? When do you want it accomplished by? Where is it to take place? And most importantly, why do you want to achieve this goal anyway? Once your client’s issue or reason for being in therapy is defined and fine-tuned, then the goal (what the situation would be if that issue were resolved) needs to be just as finely tuned.

The next step in goal setting is to think about and write out a strategy or plan which is defined as the shortest route between Point A (the issue) and Point B (the goal); and then, lining up whatever support is needed to achieve the goal becomes the next homework step. This can be done at home; and is also excellent material for your next session.

When there are many goals, prioritizing them is important; and goal prioritizing is also an excellent homework assignment. For example, consider a client who has lost his job and presents with a multitude of therapeutic issues. He may be depressed, feel a lack of direction, be experiencing a low level of self-confidence, and be nervous about a job interview. You have a litany of presenting problems: depression, the self-evaluation problem, you may have to help him deal with what his choices are with respect to which career moves are next. There might also be performance anxiety about taking the job interviews, anger at the boss who let him go, and marital problems at home as a result of all those things all triggered by this crisis. So finding out where the most energy is by having your client prioritize those issues and goals is a very important step. Doing this as homework can afford your client the quiet introspection this task deserves.

As a part of goal setting, it is also helpful to have your client break each defined goal into manageable steps or sub-goals. For example, there may be several smaller goals that are necessary to reach before taking that first job interview. After all, pushing your client to go right for something that may be perceived as extremely anxiety-producing such as (in this case) a job interview could be quite an approximation error that results in avoidance or a setup for failure. So the sub-goals are smaller steps that can be defined and attempted between sessions. They are ripe for discussion at your next session.

SUD Scale

The SUD Scale (Wolpe, 1991) is an excellent way of teaching your client to quantify his or her feelings. SUD is an acronym that stands for Subjective Units of Distress (discomfort or disturbance). It measures the degree of intensity of a particular feeling or reaction on a scale of zero to ten. If you were measuring anxiety, for instance, “zero” would be no anxiety at all. A SUD of “one” would be a very small degree of anxiety whereas a “ten” would be an extreme amount of anxiety.

This can certainly be used for a variety of applications during your session. But an effective homework assignment is to haveyour clients create a customized anxiety barometer by having them identify on the scale of zero to ten something that would help trigger each level of anxiety they could feel. For example, a SUD barometer for anxiety could look like this:

Level One. While sunbathing a rain cloud appears

Level Two. Being a little bit late for dinner reservations Level Three. Having to send food back to a restaurant Level Four. Getting caught in traffic jam

Level Five. Having a flat tire while in a rush

Level Six. Asking someone you find attractive out for date while there is a real chance of being turned down

Level Seven. Waiting outside the boss’ office when there is a possibility of being fired

Level Eight. Speaking to a large and intimidating audience

Level Nine. Waiting to hear a medical report that is potentially life-threatening

Level Ten. Driving a car that is swerving out of control toward an embankment

This is just one example of an anxiety barometer. As a homework assignment, I routinely have clients who talk about anger, depression, anxiety or guilt start keeping track of just how angry, anxious, depressed or guilty they feel during the week by identifying what their potential range of the emotion is. You will find this particularly helpful, for instance, with depressed clients who negate their progress whenever the slightest twinge of depression appears, even though they may have been depressed at an eight or nine when they first started to see you and are now down to perhaps a three or four. This is quite a significant change, but if they have the tendency to negate their progress, it may be difficult for them to keep their own perspective on how far they have come without using something like a SUD Scale to keep track of their depression at home.

You can also determine together at which SUD level it might be most appropriate for your client to approach a threatening situation. For example, in the case of the client who has lost his job and is in the process of readying himself for another job interview, you may be able to collaborate and establish a target level for anxiety on the SUD Scale as the optimal point at which he would be ready to commit to actually start taking job interviews. This approach is especially indicated for someone who has demonstrated a tendency to be characteristically avoidant. It can also be used in conjunction with several of the homework techniques to be discussed later in this article.

Mood Management

Mood management is teaching a client how to anticipate and then master a mood-when it occurs-instead of becoming overwhelmed by it. This can be used for feelings of anxiety, depression or virtually any other kind of mood situation. The first step with mood management is to have clients identify their internal triggers to the mood and then learn to see beyond them. In other words, clients need to ask themselves “What would be my situation if I could truly master this mood?” Next, clients can learn to work both during the session and at home to develop some strategies that can be employed when finding themselves in circumstances that will predictably trigger the mood. Then, by using mood-changing techniques at the appropriate moment such as certain breathing and posture exercises, they can learn a degree of empowerment over their moods.

One of my favorite mood management exercises that employs numerous techniques you can use as homework is called the “emotional fire drill” (Broder, 1992), where I have clients anticipate-that is, identify and visualize a dreaded situation (e.g., a job interview, asking someone out for a date, or giving a talk to a large intimidating audience). I ask them to imagine the situation going first the best possible way; and then to imagine it going the worst possible way. In so doing, clients can come to anticipate that in between the two extremes generally lay the reality. An emotional fire drill can be done several times a day as a way of rehearsing for an adverse situation and learning how to handle the emotion or emotions so that they in and of themselves don’t become the dreaded situation. Thus, the emotional fire drill technique helps clients to acknowledge and learn at the crucial time they need to know it, the fact that quite often it is their emotional reaction-often the discomfort anxiety-that is dreaded way more than the trigger itself.

Disputation

Disputation is perhaps the most well-known and widely used classic staple of REBT (Ellis, 1962). Disputations are generally questions that you can ask clients or, in the case of homework, clients can ask themselves. The task here both in therapy sessions and as homework is to teach clients to challenge their own irrational beliefs identified both in and out of the session.

I often have clients come up with and make lists at home of new disputations for material discussed at the last session. These client created disputations can be used whenever the situation calls for it. An example of a disputational question is “How does falling off the wagon mean that I can’t stay sober?” If a client believes “People who divorce are losers,” a disputation question might be: “If I heard that for the first time today, would I believe it?” For clients who believe that their childhood has doomed them to a life of unhappiness, they need to learn to ask themselves-between sessions-“If I had perfect parents and the best childhood of anyone I know, how would I handle (fill in the blank) differently?” This gets them into the habit of first examining and then cross-examining their own errant thinking. A client who believes “My situation won’t improve,” needs to ask, “How do I know that?” “Is that what I would tell someone I really care about who is in the same predicament?” “If not, what would I advise?” The answer to these disputation questions might prompt you to assign the client as homework to make a list of things they would advise their children to do in that situation; and you will often see an entirely different level of wisdom come out.

Affirmations

Effective affirmations are both coping statements and rational beliefs. Something that I have clients do on a routine basis at home is to make lists of their affirmations or coping statements and then look at them several times a day, even when they are not especially feeling the need to. Learning an affirmation on a deep emotional level involves not only looking at it when they are troubled by the issue, but also when they are in a more neutral or positive frame of mind. Coping statements reinforce the notion that poor self-evaluation and low frustration tolerance, and so forth are merely thinking habits. One big advantage to clients of seeing problems as thinking habits is simply that most people acknowledge that habits can be changed. This notion is a much harder sell when clients believe they are dealing with traits instead of habits.

Any time your client says something like “I never thought of it that way” as an answer to a disputation, whatever it is that they have just thought about differently is an excellent addition to their list of affirmations to be studied and reviewed at home. Some other examples of affirmations include, “I don’t have to lose my temper when I’m angry,” “I can handle this,” “I can stand it” (whatever one’s unique “it” may be), “Failing at a task does not make me a failure,” “I don’t have to give into my cravings for (fill in the blanks),” and “These cravings will pass.” It can be very helpful for your clients to put their affirmations on index cards and keep them handy for those times during the week when they are in the mood or simply ready to learn and re-learn this information.

Mood Diary

A mood diary is a written record of moods kept by the client between sessions. It can be quite helpful in identifying triggers for anxiety, anger and depression. For example, a well-kept mood diary used for anger management might contain the following information:

What triggered the angry feelings?

What am I telling myself about the trigger?

A rating of the feeling on that SUD Scale of 0 to lO?

Was my angry response to the situation helpful or harmful?

Was it really worth all the attention or energy that I expended to become enraged?

Was there anything I really could have done to make those things that triggered my anger different?

If I had it to do all over again, how would I react now?

How would I advise someone else I really cared about to react or respond in this or another similarly upsetting situation?

What could have been a response that would have disarmed me if I had acted the way my opponent did?

I generally instruct clients that we do not have to spend a great deal of session time with the details of their mood diary, since it is the triggers and patterns that are most important for us to focus on in their sessions. Still, some clients will have a need to go over their entire diary in great detail during the sessions. This is all quite negotiable, but once they begin and continue to keep their mood diary at home, a lot of the dynamics of their moods will become obvious to them.

List Making

Making lists is really a way of self-brainstorming. As homework, you can have clients make any number of lists such as “All the people who care about me,” “Things I am proud of,” “Things I can do to feel better when I’m tense,” or “A list of everything that is bothering me” (including every problem, then rank them in order as though they were totally independent of each other), then a “List of solutions.” They can refer to these lists when they are feeling isolated, lonely or depressed. If you work with single clients who believe that they can only be happy if they are in a relationship, have them make a list entitled “Twenty things I now avoid that I would be doing if I were in an ideal relationship.” They will be surprised to see that most of them can be done in one form or another either alone or with a member of their support group right now. I like long lists better than short lists because long lists challenge clients to really think. Using the analogy of exercise, I explain that the pushups one does at the very end of the set are the most beneficial ones. Encouraging clients to get beyond the things they normally think of makes the lists most helpful. And in between sessions is when they have the time to do this activity the most justice.

Another favorite list of mine to assign is “If I could do it all over again go back to age 18 or high school or when single or when married, and so on, (or whatever the hindsight-driven case may be)-what would I now do differently?” (and list twenty or more things). They will find once again that most of the entries on their list can be done in some form now. This particular exercise often helps clients to rediscover their passion while reducing their need to obsess about the past.

Guided Imagery

Guided imagery techniques such as Rational Emotive Imagery (Ellis, 1962) can be extremely powerful tools for you to teach clients to do at home. They stimulate client’s affectivity through suggestions that create imagined situations rich in therapeutic material.

You can make an imagery tape during the session of your voice that is tailored especially to clients’ issues for them to hear in the session and then re-listen to at home during the week. For example, you can have them imagine a very safe place, or becoming some other person in an interaction where they are having difficulties. If you use behavioral contingencies, you can use imagery to help them produce a list of pleasant images, such as touch or lying on a beach or a warm water effect; or unpleasant images such as loud noise, pain, rodents, or something they identify as being more specifically unpleasant. After awhile, they will begin to use these skills with very little difficulty.

One great advantage you have with audiotherapy is that the tape can actually become the therapist. Additionally, on the tape you can change the entire approach from a didactic to an experiential one. This is ideal for guided imagery between sessions. With guided imagery, you can introduce a trigger or create any situation you would as previously described with the emotional fire drill. For example, clients can create situations that may depress them on the O-to-10-SUD Scale at a nine or ten. You can then teach them how to use various mood-changing techniques to quickly reduce their feelings of depression down to a one or two. And this can be practiced over and over again at home.

A sister technique to imagery is visualization where clients visualize going to some desirable or undesirable endpoint and in their mind’s eye and then work backwards to the present. You can help your clients create a situation that would exist on the other side of the obstacles they are now facing. For example, a client feeling a great deal of anxiety about giving a talk can visualize getting a standing ovation after a superb speech.

If you are working with someone who is ending a love relationship, you can have him or her imagine themselves five years from the present with all of the emotional and practical issues now on the table, having been resolved. You can then help them to come up with a vision of what their situation might be at that blissful time five years hence. From that endpoint, you can work backwards to where they are now. If done well, the result can be a very viable set of goals and plans to get to that visualized endpoint. That is a time projection technique that combines visualization with goal setting and can be done in your office or completed at home with the exercise on tape.

Yet another variation of this technique that can be assigned as homework is to have your clients look ahead and ask “What would I do differently in my life if I had an unlimited amount of self-confidence?” Once completed, clients would then make a list of every possible answer to that question after thoroughly seeing themselves in that much improved state. If any of these visions get too difficult to do in between sessions, chances are they bring up a lot of material that is worth revisiting in the next therapy session with your help in getting through the obstacles encountered.

Relaxation and Meditation Techniques

There are many relaxation and meditation approaches clients can use in between sessions when they are anxious or stressed (Broder, 1993). Many are even available on tape. One very simple meditation technique you can teach your clients without any external props is for them to get into a comfortable posture, and with their eyes closed to think of the word “calm” while inhaling and the phrase let go on the exhale. The purpose of this is to teach clients to bring their relaxation response under their own control. This can be done for any length of time.

A more direct relaxation homework technique is (again with eyes used) for clients to count backwards from ten to one, telling themselves that at the count of one they will feel completely at peace, totally relaxed and that this relaxed state can be maintained for as long – they choose. For clients to return to an alert state, they can be instructed to count forward from one to five. At the count of five, they will be back to the present bringing the relaxation exercise to an end.

This is practiced on a daily basis-once, twice or three times a day they will soon master their relaxation response and will be able to use – practically any time as an on-the-spot technique at the first signs of stress or anxiety.

Exposure

Exposure is a well-tested procedure of choice to help clients confront an anxiety-provoking situation. By using exposure properly, clients earn to hold their own feet to the fire. To avoid an approximation error (taking steps that are too big resulting in failure), it is often wise ~o use imagery, visualization and other types of rehearsal before clients actually confront in-vivo the “dreaded” situation. Getting to this step is usually an advanced goal of therapy. By this stage, clients are ready to attempt the job interview or get into the elevator (if that is ~hat the anxiety is about) or, perhaps, to face another situation which has been long-feared. For example, if you are dealing with single clients with loneliness issues who are dreading Christmas, New Year’s eve, Valentine’s Day, their birthdays, or even a Saturday night, you can teach them to face that situation head-on with the goal of finding the formula to turn it into a positive situation, or at the very least to prove to themselves that they need not fear those occasions because they can stand (though may not like) them. Clients can benefit from assignments such as going alone to a nice restaurant, to the ballet, to a wedding or to someplace where they have repeatedly felt they could not bear to be unless they were with some special person. A good attitude to teach them is the realization that if the exposure exercise goes better than they thought, that progress has obviously been made. But if older fears are realized, it is still a no-lose situation since they have taught themselves the valuable lesson that they can handle themselves even if they did not particularly enjoy themselves. This insight greatly lessens their fear in performing the behavior again.

Thought-Stopping Techniques

Thought-stopping techniques are very effective ways of reinforcing the notion that certain negative emotions may merely be unwanted thoughts that you can learn to control (Beck et aI., 1979). A thought stopping technique is anything that interrupts the pattern or intensity of an unwanted thought. Physical activity such as exercise is often effective. The old rubber band technique where whenever clients begin to experience an unwanted thought a rubber band around their wrist is snapped, giving them a very small amount of quite harmless pain. Thinking about yelling aloud to oneself the word “stop” at the right moment can also interrupt irrational thinking. As well, clients can make a list of things that can be distracters, such as music or anything that will interrupt their negative thought process.

HOMEWORK RESISTANCE: CAUSES, CURES

What can you do with clients who do not complete agreed-upon homework assignments? The answer often lies in the very resistance to change that could be behind practically all of their therapeutic issues. Consider some of these possibilities: Perhaps, some of your homework assignments are too difficult and need to be more carefully fine-tuned. Have your “overly compliant” clients agreed to do more than they were able? Do your clients fully understand the benefits of doing homework? For example, it is possible that the rationale and importance of working on their issues between sessions has not been fully communicated. Are your clients’ non-compliance merely examples of some of the biggest reasons they are in treatment in the first place? For instance, extreme discomfort anxiety-where the issue is short-versus long-term gain-could be the saboteur in many areas. In the short-term, it may be much easier for some of your clients to avoid the immediate pain of change than to challenge themselves with the promise of reward. Likewise, for many discomfort dodgers, it is much easier in the short run to avoid doing the homework, even though in the long run the changes they are seeking in therapy may not be forthcoming. Chances are once you have identified this strand of resistance it will be related to the cause of the presenting problem itself as well as to the resistance to doing whatever it takes to resolve it.

Extremely poor self-evaluation is another possibility for clients failing to complete homework assignments. These clients may be saying to themselves that they are so ineffectual and hopeless that no matter what they do their feelings, circumstances and life will not change anyway. The issue here is hopelessness and helplessness and all the Pandora Boxes to which those issues lead. In these cases, smaller steps resulting in some success are usually called for.

Another factor that can undermine homework compliance is that of a higher order disturbance. Some clients resist solving the presenting problem because they unconsciously anticipate that the solution of one problem will trigger even more serious problems. For example, clients who resist assignments that will help them to become emotionally free of an ended love relationship, may already be fearing and thus avoiding what they have identified as the next logical step the fear of rejection in developing a new relationship. In other words, the presenting problem could merely represent what I have long called a comfortable state of, discomfort.”

With that in mind, here are some simple strategies you can employ immediately to make homework more of a staple in your treatment protocol:

Communicate the importance of homework as early in treatment as possible with emphasis on its benefits to your client.

If your sessions are limited, space them out in such a way as to make treatment as effective as possible by giving ample time to complete homework assignments and exercises. If you do that, make it clear that if your client runs into difficulty additional sessions can be scheduled. Make sure your client understands that sessions are precious commodities.

Give lots of feedback and positive reinforcement when it becomes apparent that homework was completed.

Help your client see how therapy supplements what is being done in between sessions as well as the reverse.

Use both positive and negative contingencies to shape the completion of homework assignments.

Begin sessions by following up on homework assignments. I have found this strategy to be quite helpful in staying focused on one issue at a time. By not following up, homework may be perceived by clients as not being very important. In addition, following up gives you a built-in opportunity to reinforce whatever progress has been made in between sessions.

When you teach clients to do homework you are also teaching them relapse prevention. Those same skills they have mastered in doing homework assignments are the very skills they will need to call upon when the process of life tests them, as it will, over and over again.

REFERENCES

Beck, A.T., Rush, A.J., Shaw, B.F., & Emery, G. (1979). Cognitive Therapy of Depression. New York: Guilford.

Broder, M. (1995). The Therapist’s Assistant, Volume I. Philadelphia, PA: Media Psychology Associates (available through www.therapistsassistant.com).

Broder, M. (1996). The Therapist’s Assistant, Volume II (Relationship Series).

Philadelphia, PA: Media Psychology Associates (available through www. therapistsassistant.com).

Broder, M. (1993). Self-Actualization: Techniques for Achieving Your Full Potential (on cassette). Chicago, IL: Nightingale/Conant.

Broder, M. (1992). Positive Attitude Training: The Power of Cognitive-Behavioral Psychology (on cassette). Chicago, IL: Nightingale/Conant.

Ellis, A. (1962). Reason and Emotion in Psychotherapy. Secaucus, NJ: Citadel.

Ellis, A. (1993). The Advantages and Disadvantages of Self Help Therapy Materials. Professional Psychology: Research and Practice, Vol. 24, No.3, 335-339.

Ellis, A. (1996). Better, Deeper, and More Enduring Brief Therapy. New York:

BrunnerlMazel.

Holm, K.C. (1997). Writer’s Market. Cincinnati, OR: Writer’s Digest Books, a Division of F&W Publications.

Wolpe, J. (1991). The Practice of Behavior Therapy (4th edition). New York:

Pergamon Press.

Abstract

The current study was an updated meta-analysis of manuscripts since the year 2000 examining the effects of homework compliance on treatment outcome. A total of 23 studies encompassing 2,183 subjects were included. Results indicated a significant relationship between homework compliance and treatment outcome suggesting a small to medium effect (r = .26; 95% CI = .19–.33). Moderator analyses were conducted to determine the differential effect size of homework on treatment outcome by target symptoms (e.g., depression; anxiety), source of homework rating (e.g., client; therapist), timing of homework rating (e.g., retroactive vs. contemporaneous), and type of homework rating (e.g., Likert; total homeworks completed). Results indicated that effect sizes were robust across target symptoms, but differed by source of homework rating, timing of homework rating, and type of homework rating. Specifically, studies utilizing combined client and therapist ratings of compliance had significantly higher mean effect size relative to those using therapist only assessments and those using objective assessments. Further, studies that rated the percentage of homeworks completed had a significantly lower mean effect size compared to studies using Likert ratings, and retroactive assessments had higher effect size than contemporaneous assessments.

Keywords: Psychotherapy, Depression, Anxiety, Substance use, Homework

Introduction

Cognitive and behavior therapies are often considered “first-line” treatments for a number of psychiatric disorders, with various meta-analyses demonstrating the efficacy of these therapies for conditions such as anxiety disorders (Hofmann and Smits 2008; Otto et al. 2004), depression (Dobson 1989; Spek et al. 2007), and substance-use disorders (Duttra et al. 2008). While cognitive and behavior therapies have been established on theoretical foundations, the efficacy of these interventions may lie in their strong history of utilizing homework assignments as a mechanism toward producing beneficial treatment outcomes. That is, practice of skills outside of therapy (i.e., homework) allows clients to master the skills believed necessary to affect symptoms, generalize these skills to their natural settings, and promote prolonged symptom improvement through extending therapeutic aspects of treatment beyond the completion of therapy (Kazantzis and Lampropoulos 2002).

Indeed, the importance of homework for producing positive therapy outcome was demonstrated in a previous meta-analysis (Kazantzis et al. 2000). In their analysis, a Pearson r effect size of .22 was reported for the relationship between homework compliance and therapy outcome in a sample of 1,327 subjects across 27 studies. These results suggest that greater compliance with homework is associated with beneficial treatment outcome, with the strength of the association falling between Cohen’s small and medium effect size cutoffs (Cohen 1988; Kraemer et al. 2003).

Kazantzis et al. (2000) analysis was the first study to examine the type of homework activity and the nature of the client’s presenting problem as moderating variables of homework effectiveness. The presenting problems were categorized as depression, anxiety-related disorders, and other outpatient. The results of this meta-analysis showed the following mean effect sizes for problem type: depression (.22), anxiety (.24), and other outpatient (.17), with homework effects being significantly greater for the treatment of depression than the “other outpatient” sample. Additionally, results indicated that effect sizes were robust across the type of homework completed (no single type, relaxation, or social skills) and time of homework compliance assessment (regular intervals or posttreatment), but differed by the source of homework compliance assessment. Specifically, studies that utilized client and therapist ratings had a significantly lower mean effect size relative to those using objective measures of homework compliance.

In the 8 years since Kazantzis, Deane, and Ronan’s meta-analysis on the effects of homework assignments on treatment outcome, homework has continued to remain “both a traditional and integral component of contemporary manual-based cognitive-behavioral therapy (CBT) approaches” (Coon and Thompson 2003, p. 53). Further, there continues to be support for the effectiveness of cognitive-behavioral interventions to prevent the onset, relapse, and recurrence of a number of psychological disorders (Hollon 2003). The meta-analysis conducted by Kazantzis et al. (2000) included homework-related studies spanning from 1980, 1 year following Beck’s emphasis on regularly using homework in cognitive-behavioral therapy for depression (Beck et al. 1979), through 1998, a time when homework in therapy had been incorporated into a more diverse range of clinical conditions (Kazantzis et al. 2000). Therefore, a significant amount of variance as a function of time may exist within this analysis.

The present study is an updated meta-analysis of the relationship between homework compliance and treatment outcome. We hypothesized that greater homework compliance would be significantly associated with improved treatment outcome. Given that the previous meta-analysis found some evidence that targeted symptoms and source of homework ratings may moderate the effect of homework compliance, we further examined whether treatment target (e.g., symptoms of anxiety, depression, etc.) and source of rating (e.g., therapist, objective) moderated the relationship between homework compliance and therapy outcome. A novel aspect of this meta-analysis is that we examine the moderating effect of rating type (e.g., Likert rating, percentage of homeworks completed).

Methods

Sample

To identify candidate studies for inclusion in our review, the following inclusion/exclusion criteria were used: (a) studies must have been published between January, 2000 and September, 2008, (b) the study must have been published in English, and (c) the study must have been a treatment study examining pre- and post-treatment outcome and measured some aspect of homework compliance. Guided by these criteria, we searched PsychArticles, PsychInfo, and Medline databases for journal manuscripts published between January 2000 and September 2008 using the key terms homework and compliance and (therapy or psychotherapy or psychosocial intervention or intervention). From this search 87 articles were found. We read the abstracts from these articles to identify potential studies for inclusion as well as manuscript citations to identify further manuscripts that may have initially been missed in our initial search. Articles that were eliminated dealt with methods for improving homework compliance rather than the impact of homework compliance on treatment outcome. Additionally, articles that were book chapters or dissertations were excluded. Twenty-three studies encompassing 2,183 subjects met the inclusion criteria for the meta-analysis and were therefore included in the present study.

Classification and Coding Systems

Only studies looking at the relationship between homework compliance and the therapeutic outcome were included in the present study. In addition to the relations between homework compliance and outcome, the following elements were considered as moderator variables:

  1. Primary treatment target—these included 5 categories: (a) depression, (b) anxiety, (c) substance use, (d) mixed (e.g., both anxiety and depression), and (e) other (e.g., functioning);

  2. Source of homework rating—Four categories were included in this rating: (a) therapist (Likert rating), (b) client (Likert rating), (c) objective (e.g., number of assignments turned in), and (d) client and therapist (e.g., both client and therapist rated homework compliance and average ratings were used).

  3. Type of homework rating—Three categories of homework rating were coded: (a) Likert scale, (b) number of assignments completed, and (c) percentage of homework completed.

  4. Timing of homework rating—Two categories of timing were coded: (a) retroactive ratings of homework compliance (e.g., a single rating at the end of treatment), and (b) contemporaneous ratings of homework compliance (e.g., assessment of homework at each therapy session).

  5. Year of study—In this analysis, we used weighted regression to determine if the linear variable “year of publication” moderated the effect size of homework on outcome.

Calculation of Effect Sizes

Effect size r was used to characterize the relationship between homework compliance and therapy outcome for each of the 20 studies. For studies that did not report correlation coefficients (r), available study statistics were converted to r according to standard formulas (Hunter and Schmidt 1990). As mentioned above, effect sizes were determined by two independent reviewers and for the majority of studies agreement was reached. In three cases, discrepancies were determined by discussion between the two reviewers and a third reviewer. For those studies where available statistics were not readily converted to r, we used the standardized regression coefficient (β; n = 7) or semi-partial correlation coefficient (n = 3) as a proxy for r (Peterson and Brown 2005). Once study-level correlation coefficients were calculated they were weighted, aggregated, and their heterogeneity was assessed with the Q statistic (Hedges and Olkin 1985) using a random effects model.

Results

Characteristics of the Sample

Characteristics of the 23 studies included in this meta-analysis are presented in Table 1. Overall, the number of participants in these studies ranged from 10 to 641, with a mean of approximately 95 participants (median n = 46). Eight studies targeted symptoms of anxiety, 5 targeted symptoms of depression, 3 targeted substance use, and 1 targeted a mix of symptoms. The remaining 6 studies targeted a variety of symptoms including psychosis, body image, and everyday functioning; these were coded as “other”. As for the source of homework ratings, 11 used therapist ratings, 2 used client ratings, 8 used an objective rating, and 2 used both client and therapist ratings. A total of 9 studies used a Likert rating of homework compliance, 7 used the number of homework assignments completed, and 7 used the percentage of homeworks completed.

Effects of Homework Compliance on Therapy Outcome

The overall effect size r between homework compliance and treatment outcome was .26 (95% CI = .19–.33; P < .001), indicating that across treatment targets, sources of homework ratings, and type of homework ratings, greater homework compliance was associated with improved treatment outcome. The overall effect fell within the small-to-medium range (Cohen 1988). This result supported our first hypothesis. Effect sizes ranged from .08 to .93, and the homogeneity analysis indicated significant heterogeneity in results (Q = 39.38, df = 19, P = .004). The fail-safe n (Rosenthal 1979) was computed to be 618.

Moderator Analyses

Results of our 3 moderator analyses are presented in Table 2, and information on study details (e.g., duration, modality, outcome measures) are found in Table ​3. Our first moderator analysis examined the effect of homework on treatment outcome by treatment target (e.g., symptoms of anxiety or depression). Overall, treatment target did not significantly moderate the relationship between homework compliance and treatment outcome (Q = .39, df = 4, P = .983). As seen in Table 2, the effect sizes were remarkably robust, ranging from .22 for anxiety to .27 for substance use outcomes.

Our second moderator analysis examined the source of homework ratings (e.g., therapist, client). Results of this analysis indicated a significant moderating effect of homework source (Q = 13.83, df = 3, P = .003). Studies that utilized combined client and therapist ratings had a significantly larger mean effect size than those that utilized objective ratings (P < .001). No significant differences were observed between the other sources of homework ratings.

Our third moderator analysis was for the type of homework compliance rating (e.g., Likert scale). Results of this analysis indicated that type of homework rating significantly moderated the relationship between homework compliance and therapy outcome (Q = 9.51, df = 2, P = .009). Post-hoc analyses indicated that studies utilizing Likert ratings of homework compliance had a significantly higher mean effect size compared to studies using a percentage rating (i.e., percentage of homeworks completed) of homework compliance (P = .002). No significant differences were observed between Likert and total number of homeworks completed or between total number completed and percent completed (P-values > .05).

Our fourth analysis was for timing of homework compliance (e.g., retroactive vs. contemporaneous). Results of this moderator analysis indicated that retroactive ratings of homework compliance (e.g., a single rating of compliance provided at the end of treatment) demonstrated a significantly higher effect size than contemporaneous ratings (e.g., ratings made after each therapy session; Q = 11.90, df = 1, P < .001). Specifically, the mean correlation between homework compliance and outcome was .36 for retroactive ratings and .19 for contemporaneous ratings.

A final analysis examined the moderating effect of publication year. Results of this analysis indicated that year of publication did not moderate the effect of homework on treatment outcome (P = .264).

Discussion

This meta-analysis examined the relationship between homework compliance and treatment outcome across 23 studies and over 2,000 participants. Similar to results found by Kazantzis et al. (2000), greater homework compliance was associated with improved treatment outcome (r = .27). These results were consistent across a variety of target symptoms including symptoms of anxiety (r = .22), depression (r = .24), and substance use (r = .27), suggesting that compliance with homework is an important component of psychotherapy regardless of the target symptoms. Indeed, this finding is consistent with cognitive and behavioral theories, which suggest that mastery of skills learned in therapy via practice of such skills is important for producing positive treatment outcomes (i.e., improving symptoms).

In the present study, the two most common sources of homework ratings were therapists and objective ratings (e.g., counting the number or percentage of homework turned in), and we found that the source of homework ratings moderated the relationship between homework compliance and treatment outcome. Specifically, when both clients and their therapists provided homework ratings, effect sizes were significantly higher (r = .35) than when objective ratings were used (r = .16). However, because only two studies utilized both client and therapist ratings, these results should be interpreted with caution. Indeed, the two studies that utilized therapist and patient ratings of compliance used quite different methods for assessing homework compliance and had quite different sample sizes. Moreover, our analysis averaged the therapist and patient rating of homework compliance, despite the fact that these ratings may not always be strongly correlated. Indeed, the study by Westra and Dozois (2006) reported only a modest correlation between therapist and client compliance ratings. Again, given the small number of studies utilizing this method and the limitations mentioned here, readers should take caution about interpreting these findings as particularly meaningful.

These findings might be interpreted in a number of different ways. First, they may suggest that future studies of this relationship should utilize both types of ratings, at least on the assumption that this effect size discrepancy is real. Alternatively, this discrepancy in findings might highlight the inherent limitations of using “subjective” ratings as a means of assessing homework compliance. For example, therapists who provide homework ratings may give better scores to those who are doing better in therapy (i.e., “he’s doing better, so he must be doing his homework”).

There were no significant differences between groups when comparing other sources of homework ratings. However, although objective ratings did not differ from client alone or therapist alone ratings, it is interesting to note that our findings differ from those of Kazantzis et al. (2000), who found that objective ratings had a higher overall correlation with treatment outcome. This may be due to the difference in defining “objective” assessment between the two meta-analyses. Specifically, whereas Kazantzis defined “objective” as an electronic marker of homework compliance, our analysis considered “objective” to mean studies that counted the number of homeworks turned into therapists.

Studies that used Likert scales to rate homework compliance had a significantly higher mean effect size (r = .31) than those rating the percentage of homeworks completed (r = .17). Further, studies using Likert scales were higher, but not significantly so, than studies using the number of homeworks completed. While this finding is difficult to explain, it may be due to the fact that Likert ratings might inadvertently reflect quality and quantity ratings, whereas a summary variable such as percent or total homeworks completed reflect quantity only. For example, during the course of therapy, clients may be asked to regularly (e.g., once each day) practice homework. However, they may present at the next therapy session and describe one excellent (and extremely beneficial) example of how he/she practiced homework over the past week. Therapists who rated client homework from 0 (poor) to 6 (outstanding) might rate this compliance relatively high on the scale. In contrast, clients who report doing homework every day but who had difficulty with the assignment or who described it as unhelpful might be rated relatively lower in terms of compliance. Further, Likert scales provide the therapist and the client with a range to rank homework completion. This can be opposed to percentage of homeworks completed and number of homeworks completed, which are often scored on a dichotomous (completed or did not complete) scale. If a client completes part of a homework assignment, the client is given some credit for compliance, even if the effort is minimal.

Further, a “timing effect” was found for contemporaneous versus retrospective ratings of homework completion in that retrospective ratings were a significantly better predictor of outcome than contemporaneous ratings. This may have been due to a bias effect for retroactive ratings. For example, it is possible that patients who have appeared to have done well in therapy could have been rated by their therapist or themselves as more compliant with homework assignments. These results may provide insight into differences in objective versus subjective ratings (i.e., higher effect size for subjective ratings than objective assessments), in that objective ratings are most typically contemporaneous by nature (e.g., paperwork that was turned into and/or discussed with the therapist), and therefore appear more reliable in assessing compliance than retroactive or subjective ratings of compliance.

These issues (objective vs. subjective; Likert vs. non-Likert) highlight the important issue of how we define homework compliance. Specifically, they highlight the important issue of the purpose of conducting a homework analyses, which is to discover the “true nature” of the relationship between homework compliance and treatment outcome, not findings ways of manipulating methods to demonstrate larger effects. Determining the true effect indeed involves finding increasingly “objective”, or bias-free methods of assessing homework compliance. To this end, Kazantzis et al. (2004) has described novel methods of assessing homework in therapy research (e.g., the Homework Rating Scale), which include the assessment of homework quality. However, there has yet to be any consistent use of these methods. We strongly recommend new research incorporate these new methods of assessing homework compliance, as well as develop more objective and accurate means of assessing homework quantity and quality in treatment research and outcome.

There are several limitations to the current review. As previously mentioned, there have been problems with the objective assessment of homework compliance. Additionally, the current review did not examine demographic moderators (i.e., age, gender, ethnicity, education) or the severity of psychopathology (e.g., Major Depressive Disorder vs. Dysthymia; Substance Abuse vs. Substance Dependence) that could contribute to homework compliance. These variables were not included in the current study’s moderator analysis as they were not examined in the results of the studies reviewed. Research has found that clients comply less with homework directives if they have greater and/or more long-lasting symptomology (Worthington 1986). In addition to demographic moderators and severity of psychopathology, other things to keep in mind when considering the relationship between a client’s homework compliance and therapeutic gain are pharmacotherapy (e.g., is the client on antidepressant medications?), if the client is involved in another form of treatment (e.g., social skills training), and use of coping mechanisms for dealing with stress (e.g., does the client take action in response to stress or become less productive? Addis and Jacobson 2000). The results, however, demonstrate a more generalized view of the effects of homework compliance on therapy outcome across a span of different psychological diagnoses and diverse demographic characteristics.

A further limitation of the current review is that it did not take into account the client-therapist relationship. Research has found that a positive and trusting client-therapist relationship may aid recovery in mental illness (Green et al. 2008) regardless of homework. Additionally, the strength of the relationship between the client and the therapist could contribute to homework compliance, with a stronger working relationship leading to increased homework compliance. Without looking at the client-therapist relationship as a moderator between homework compliance and treatment outcome, there is a possibility that the relationship alone contributed to the improvements seen in the clients. However, as mentioned by Kazantzis et al. (2000), there exists an abundance of research that demonstrates the positive effects of the use of homework in therapy on treatment outcome.

Finally, the current review did not examine the client’s attitude towards homework. A negative attitude towards homework, even if the homework is completed, could potentially limit the likelihood that the client will continue to practice the skills learned once therapy is completed. Motivation, lack of effort, and readiness to change are other variables that were not explored in the current study, which are factors that have been found to be correlated with homework compliance (Neimeyer et al. 2008; Yovel and Safren 2007). Addis and Jacobson (2000) examined the relationship between clients acceptance of the treatment rationale and the degree to which clients completed homework, and concluded that the ability to provide a convincing treatment rationale may be one of the crucial skills which determines the success of CBT in real-world clinical settings. Further studies would benefit from exploring these areas in regard to homework compliance.

In sum, the results of this meta-analysis suggest that on the whole, greater compliance with homework is related to improved treatment outcome, and this relationship is robust across a variety of treatment targets (e.g., depression, anxiety, and substance use). However, this study also highlights discrepancies in effect sizes surrounding the method of assessing homework compliance (e.g., objective vs. subjective). Specifically, higher effect sizes were found when therapists and clients both evaluate homework compliance. On one hand, clinicians may desire making homework compliance a collaborative part of treatment (e.g., to structure therapy whereby review of homework is an integral part of sessions). On the other hand, these discrepancies may highlight the inherent limitations in using subjective assessments of homework compliance. To this regard, it may be increasingly important for more standardized and objective methods of assessing homework compliance that are less prone to bias and that capture the true nature of the relationship between homework compliance and treatment outcome. In this vein, suggestions on incorporating homework into therapy and improving compliance are available in the literature (Beck 1995; Tompkins 2004), as are forms for measuring multiple aspects of homework compliance (Kazantzis et al. 2004).

Acknowledgments

Funding for this manuscript was provided by the National Institute on Aging (NIA) through grant R01 AG031090 and the National Institute of Mental Health (NIMH) through grant R01 MH 084967.

Open Access This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

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