Effects of Homework in Therapy Sessions

Activities given to clients to complete in between therapeutic sessions have become a commonly used component of psychological therapies, especially cognitive approaches (Beck et al., 1979). What is sometimes called ‘homework’ has been used to help address a wide variety of clinical problems including depressive disorders, schizophrenia and social phobia. This essay critically examines the empirical studies on homework and its influence on treatment outcomes.

The term ‘homework’ can include a wide variety of different activities given to clients. Scheel et al. (1999) provide some typical examples of those most often used by cognitive therapists: those involving reframing meanings, validation of internal experiences, social interactions and decision making. It has been hypothesised that homework is effective by encouraging the client to practice new skills learned in therapy outside of those therapeutic sessions (Burns, Adams & Anastopoulos, 1985). While the term homework has been criticised for its unpleasant connotations with schoolwork (Coon et al., 2005), the real, practical question is whether the process itself actually improves patient outcomes.

Despite its broad use within cognitive therapy, there has been relatively little research into its effectiveness until recently (Kazantzis, Deane & Ronan, 2000). Broadly two types of studies have been carried out to examine the effect of homework on treatment outcomes: correlational and those with a control group. Correlational studies have generally found a positive association between adherence to homework and a more positive outcome. For example Burns and Spangler (2000) found that compliance to homework was significantly associated with reduced depression. These authors also report that their effect sizes were large, translating to an average reduction of 16.6 points on the Beck Depression Inventory for those who completed their homework compared with a reduction of only 2.4 points for those who did little (or no) homework. Other studies have also reached similar conclusions (e.g. Burns & Nolen-Hoeksema, 1991; Leung & Heimberg, 1996). Despite these positive results these types of studies are always open to the criticism that they are weak evidence because of their correlational design. It may be, for example, that homework compliance is simply a result of improvement rather than a cause.

Better designs incorporating a control group which can, therefore, impute causality have not produced such definitive results, are far fewer, and older. Some have shown positive effects for homework (e.g. Kazdin & Mascitelli, 1982), while others have failed to show a positive effect (e.g. Blanchard et al., 1991). This uncertainty was underlined by a meta-analysis of both the correlational and control group studies carried out by Kazantzis et al. (2000) which reported a weighted average effect size for 27 such studies as 0.36 – only a small to moderate effect far smaller than that reported by Burns and Spangler (2000). This meta-analysis has also been criticised for including studies that were not controlled and some which had poor designs (Lambert, Harmon, & Slade, 2007).

The majority of studies since Kazantzis et al.’s (2000) meta-analysis have also been correlational. Coon and Thompson (2003), for example, examined the use of homework in older adults with mild to moderate depression. Using a regression analysis they found homework was associated with better outcomes – but this is still effectively only correlational data. Rees, McEvoy and Nathan (2005) recruited participants with both anxiety and depression and found homework was associated with better outcomes. But, again this study was correlational in design. For anxiety disorders, however, even correlational studies have proved less conclusive than for depression. Some studies of anxiety have found positive correlations (e.g. Wetherell et al., 2005), while others have not (e.g. Woody & Adessky, 2002). For more serious mental disorders such as schizophrenia, empirical work is only just emerging and the results of two studies have found no relationship between improved schizophrenia symptoms and homework compliance (Dunn, Morrison & Bentall, 2006; Granholm et al., 2006).

In conclusion, the picture emerging from the empirical literature is positive for the effect of homework compliance on outcome only when the correlational data is examined. This work suggests mild to moderate depression is responsive to homework, while anxiety disorders and psychosis is less so. Unfortunately these types of studies find it difficult to counter the argument that homework compliance is simply a result of a better outcome, rather than a cause. Controlled experimental designs, which can make this causal distinction, have been few and are generally much less conclusive. Consequently, while the use of homework in cognitive therapy seems likely to do little harm (although the term may have some stigma attached), the extant research is yet to definitively demonstrate it has more than a marginal benefit.

References

Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy for depression. New York: Guildford Press.

Blanchard, E. B., Nicholson, N. L., Radnitz, C., Steffek, B. D., Appelbaum, K. A., & Dentinger, M. P. (1991). The role of home practice in thermal biofeedback. Journal of Consulting & Clinical Psychology, 59, 507-512.

Burns, D. D., Adams, R. L. & Anastopoulos, A. D. (1985). The role of self-help assignments in the treatment of depression. In: E. E. Beckham & W. R. Leber (Eds.), Handbook of depression treatment, assessment, and research (pp. 634-668). Homewood, IL: Dorsey Press.

Burns, D. D., & Nolenn-Hoeksema, S. (1991). Coping styles, homework compliance, and the effectiveness of cognitive-behavioral therapy. Journal of Consulting & Clinical Psychology, 59, 305-311.

Burns, D. D., & Spangler, D. L. (2000). Does psychotherapy homework lead to improvements in depression in cognitive-behavioral therapy or does improvement lead to increased homework compliance? Journal of Consulting & Clinical Psychology, 68, 46-56.

Coon, D. W., & Thompson, L. W. (2003). The relationship between homework compliance and treatment outcomes among older adult outpatients with mild-to-moderate depression. American Journal of Geriatric Psychiatry, 11, 53-61.

Coon, D. W., Rabinowitz, Y. G., Thompson, L. W., Gallacher-Thompson, D. (2005). Older Adults. In: N. Kazantzis, F. P. Deane, K. R. Ronan & L. L’Abate (Eds.). Using Homework Assignments in Cognitive-behavioral Therapy (pp. 117-152). New York: Routledge.

Dunn, H., Morrison, A. P., & Bentall, R. P. (2006). The relationship between patient suitability, therapeutic alliance, homework compliance and outcome in cognitive therapy for psychosis. Clinical Psychology and Psychotherapy, 13, 145-152.

Granholm, E., Auslander, L. A., Gottlieb, J. D., McQuaid, J. R., & McClure, F. S. (2006). Therapeutic factors contributing to change in cognitive-behavioral group therapy for older persons with schizophrenia. Journal of Contemporary Psychotherapy, 36, 31-41.

Kazantzis, N., Deane, F., & Ronan, K. R. (2000). Homework assignments in cognitive behavioral therapy: A Meta-Analysis. Clinical Psychology: Science and Practice, 7, 189-202.

Kazdin, A. E., & Mascitelli, S. (1982). Covert and overt rehearsal and homework practice in developing assertiveness. Journal of Consulting and Clinical Psychology, 50, 250-258.

Lambert, M. J., Harmon, S. C., & Slade, K. (2007). Directions for future research on homework. In: N. Kazantzis & L. l’Abate (Eds.). Handbook of homework assignments in psychotherapy (pp. 407-423). New York: Springer.

Leung, A. W., & Heimberg, R. G. (1996). Homework compliance, perceptions of control, and outcome of cognitive-behavioral treatment of social phobia. Behaviour Research & Therapy, 34, 423-432.

Rees, C. S., McEvoy, P., & Nathan, P. R. (2005). Relationship between homework completion and outcome in cognitive behaviour therapy. Cognitive Behaviour Therapy, 34, 242-247.

Scheel, M. J., Seaman, S., Roach, K., Mullin, T., & Mahoney, K. B. (1999). Client implementation of therapist recommendations predicted by client perception of fit, difficulty of implementation, and therapist influence. Journal of Counseling Psychology, 46, 308-316.

Wetherell, J. L., Hopko, D. R., Diefenbach, G. J., Averill, P. M., Beck, J. G., Craske, M. G., et al. (2005). Cognitive-behavioral therapy for late-life generalized anxiety disorder: Who gets better? Behavior Therapy, 36, 147-156.

Woody, S. R., & Adessky, R. S. (2002). Therapeutic alliance, group cohesion, and homework compliance during cognitive-behavioral group treatment of social phobia. Behavior Therapy, 3, 5-27.