Have you done your therapy homework today?
There was a time when psychotherapy meant reclining on a comfortable sofa, free-associating to a silent “all-knowing” therapist. It may not have done much to treat anxiety disorders, but it was comfortable and risk-free.
If you are serious, however, about treating your anxiety disorder, a very different and much more effective approach is required: Cognitive-Behavioral Therapy (CBT) with an emphasis on Exposure with Response Prevention (ERP). This approach involves taking concrete steps towards changing your thoughts, beliefs, and behaviors in order to lessen your anxiety.
This requires committing yourself to hard and often uncomfortable work in the short term in order to live a more comfortable future. Typically, this means “homework” and lots of it!
Yes. I agree that coming to therapy once a week and getting a pleasant dose of supportive reassurance might (in the short term) be more enjoyable than coming to therapy and doing challenging things like ERP, only to leave with homework assignments for the week. If research showed that the former worked, I’d gladly do that type of therapy.
Research, however, consistently shows that CBT is the non-medical treatment of choice for anxiety disorders. Consequently, if you are serious about managing your anxiety disorder, then challenging yourself with CBT (and the homework that comes along with it) is what gives you your best chance of victory.
The rule-of-thumb with CBT is that you get out of it what you put into it. Ultimately, you are the only one who can make the choice to face your fears and therefore (assuming you have access to appropriate anxiety diagnostic, treatment, and support resources) you are responsible for the success of your treatment.
What types of homework might be expected of me?
Since the types of things people fear are limitless, the content of your homework could be anything. Early on, you will likely be given questionnaires and other “data-collection” tasks to do. Then, you will need to learn about your anxiety through hand-outs, book recommendations, and/or internet information sources (You’re doing that right now…good for you!).
Then, you will be taught specific CBT and ERP skills and will be expected to practice regularly outside of therapy. Some people will also be taught specific social, problem-solving, relaxation, or acceptance-based skills that they will be expected to practice regularly.
How much time will I need to devote to homework assignments?
That depends. With severe anxiety disorders, I typically recommend that clients budget a minimum of one hour daily, six to seven days per week for the first month or so. I know that finding an extra hour for ERP each day is challenging, but here’s the deal—research shows that exposure therapy works best when exposure sessions occur frequently and for longer durations. You will likely make more progress in two weeks if you spend four hours a day, seven days a week doing ERP than spending ten years doing ERP once a week for fifteen minutes.
What are some reasons why people do not do their homework?
Lack of understanding of the importance of therapy homework is the most likely reason (“I’m terrified of dogs. Why on earth would I want to interact with one?”). Everyone who engages in CBT or ERP needs to have a reason to do so that makes sense to them. Do you really want to do something that someone else tells you is a good idea, is very uncomfortable, and makes no sense as to why you ought to do it? I thought not. If you are serious about getting your anxiety disorder under control, ask questions, read appropriate self-help or psycho-educational materials, and if you can, talk to people who have had a similar problem and have treated it successfully. Take charge of your own anxiety by becoming informed.
Some people feel pressured to come for treatment. Perhaps a spouse or parent is giving you an ultimatum—get treatment or else! By coming to therapy, you grudgingly meet the externally imposed mandate and by NOT doing your therapy homework you get to fail at therapy and tell the people who are pressuring you, “See, it doesn’t work”, ensuring that they will get off your back. Change is unlikely without sufficient motivation.
For some, the discomfort they fear they will have with ERP feels too painful for them to undergo. In this case, perhaps they (or their therapist) have set too challenging of a homework task—it happens. This can be resolved by either learning anxiety coping skills prior to ERP or breaking the task up into smaller steps. There is always a micro-step, so find it and repeat it until it is less distressing, and then take the next micro-step. If you are devoting an hour or so to ERP a day, those micro-steps can add up to substantial progress quickly.
Homework usually means changing a problem behavior that may be very automatic. Avoidance is a hard habit to break for many. Genuine ambivalence is common among people contemplating facing their fears. Early and honest discussion of this with your therapist is important in order to reduce the likelihood of being assigned homework that you are not yet ready to undertake. If you are still not sure that you want to make a change, it is not appropriate for you to be sent home from therapy with an ERP action plan for the week. Therefore in these cases, your initial homework is best focused on seeking information and bolstering motivation. If the reasons for making a difficult change does not sufficiently outweigh the reasons for continuing your avoidance then it is likely NOT the right time to treat your anxiety disorder. Better to be honest about this upfront and cease CBT/ERP rather than accumulating a list of half-hearted homework “attempts” and failures and concluding that this treatment doesn’t work for you.
It is common for people with severe anxiety disorders to also be depressed. Depression saps one’s motivation to engage in pleasurable activities so it certainly presents a challenge for completing tasks that might be scary, such as facing a feared situation. Often depression will need to be treated prior to treating an anxiety disorder.
While there may be the hope that your anxiety disorder can be overcome, there may be a stronger belief that it is just not possible toget better, that maybe you are too far gone. This can certainly impact one’s willingness to do ERP. Talk to your therapist about your concerns. It is important for you to know that people CAN learn to manage their anxiety disorder even if it is severe and has gone on for many years. It will, however, take consistent work on your part to make that happen.
While some people are open to trying new things if it seems like it might help them with a problem, there are some people whose personality is greatly defined by resisting help from other people. Some of us tend to be just plain oppositional. If you put someone like that in therapy and ask them to do something differently, they are likely to dig their heels in even deeper. The more they are pushed the harder they resist. If this describes you then your best bet for improving your anxiety is to become an expert in your anxiety. Do it for you and no one else. Don’t go to therapy to get told what to do, but “hire” a therapist with an expertise in your anxiety disorder and utilize them as a consultant in your self-directed treatment. Just be sure to be up front about this so that the therapist understands his or her role.
There are others whose personality is characterized by a more passive, dependent, or avoidant stance. These are people who have a consistent pattern across many facets of their life that revolve around either avoiding unpleasant things or enlisting someone else to do unpleasant things for them (or at least accompany them). If this is your personality, then your anxiety might be managed best if you can push yourself to take on ERP challenges more independently, initially enlist someone as an anxiety coach in the early stages, or enroll in a more intensive treatment program where, at least initially, you could have more one to one time with your therapist while doing exposure activities.
Most people would agree that discomfort is a normal and natural part of life. Some people, however, carry a belief that they “should always be comfortable”. This is a Thinking Trap that propels people towards a never-ending quest for comfort. The more you try to stay always-comfortable, the more your ability to tolerate discomfort diminishes. Chasing comfort, therefore, can make your world quite small and your activities very limited. Discomfort IS normal and building up a tolerance for discomfort is actually part of some anxiety treatment protocols.
For someone with a severe anxiety disorder, treatment needs to be a top priority in order to ensure that sufficient time and attention is devoted to taking those steps needed to get better. In life, however, illnesses, crises, time-consuming work obligations, or other genuine obstacles may present themselves. There are, in fact, worse times to treat anxiety disorders than others. Sometimes other life events DO need to take priority. That’s not to say that you cannot treat your anxiety in the face of other problems or obligations, but being realistic about your time constraints (and competing priorities) is important in deciding when to proceed with treatment and at what level of intensity. If you really are unable to make anxiety treatment a very important priority in your life, discuss this with your therapist and decide together whether to postpone treatment or to briefly shift focus.
There are also therapist issues to consider such as whether they have an expertise in ERP and are willing to work within established CBT treatment protocols. If you are concerned whether the types of homework assignments are appropriate for treating your anxiety disorder, ask questions, read anxiety educational materials, and get informed. If you are working with a therapist who you feel does not understand the problem for which you are seeking treatment, or you simply are not “hitting it off” then discuss this with him or her and look for another treatment provider. It is important that you feel your concerns are being addressed. It is difficult to do therapy homework when you have a poor relationship with the therapist who has recommended your daily ERP tasks.
Some people do not follow-through with therapy homework assignments because of the “secondary gains” they receive from maintaining an anxiety disorder. For example:
- Disability payments
- Additional attention and support from friends and family
- More time with kids, parents, or partners
- More time to pursue other interests (read—not having to work)
- Maintaining a status quo
- Getting out of chores or other obligations
- Avoiding other normal life discomforts
Maintaining an anxiety disorder in order to receive secondary benefits is typically NOT something people are aware they are doing. They may attend therapy for the attention or because they are pressured by others, but taking consistent steps towards real improvement is typically absent because getting better would lead to losing something they do not want to lose. The unfortunate thing is that in many cases the benefits from overcoming their anxiety disorder would greatly outweigh the benefits they are receiving from their secondary gain—they just can’t see it. Sometimes the secondary gain is to relieve pressure from someone else. For example, a child with separation anxiety may refuse to leave home to go to school partly because of unspoken pressure to support a depressed parent’s dependency needs (in other words the parent is meeting one of their needs by having a “sick” child).
What should I do if I cannot get myself to follow through with homework assignments at all?
That depends on a number of factors and I recommend that you discuss this with your therapist. However, here are some possible approaches:
- Explore with your therapist the pros and cons of treating your anxiety
- Work with therapist on problem-solving or decision-making skills
- Treat an interfering condition first
- Put off treatment until you are ready (or seek more supportive treatment first and work on basic motivational issues)
- Find a therapist who has more expertise on treating your problem (for anxiety disorders check www.adaa.org for a list of therapists who belong to the Anxiety Disorders Association of America)
- Work with your therapist to take smaller steps
- Make sure you understand (and agree with) the rationale for doing CBT homework
- Tell supportive people your goals (making it public increases likelihood of follow-through)
- Enlist a friend or family member as an anxiety coach to cheer you along as you complete your homework
- Schedule homework into your day
- Make it a top priority
- Reward yourself after completing your homework (perhaps only watch TV after your homework is done)
- Generate bigger incentive such as taking a vacation if you follow-through on your homework for a month
- Impose a negative consequence for not doing your homework (such as giving money to a charity you despise)
- Consider a more intensive treatment (such as an intensive outpatient IOP program or an inpatient or residential anxiety treatment program) where you will do more of your ERP with a therapist present
- Stop treatment for a set amount of time (teachers might hold off on treatment until they are off of teaching for the summer)
In sum, there is good news and bad news. The bad news is that for many people with an anxiety disorder, they will not get better unless they follow-through with appropriate, but potentially unpleasant treatment assignments. The good news is that with follow-through on these assignments most people will improve their anxiety significantly.
Eric Goodman, Ph.D.
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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
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).
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:
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);
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).
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.
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).
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.
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.
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).
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).
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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