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Assessing Compliance With Homework Assignments: Review and Recommendations for Clinical Practice т. Nikolaos Kazantzis. Massey University т. Frank P.

Assessing Compliance With Homework Assignments: Review and Recommendations for Clinical Practice 䊲

Nikolaos Kazantzis Massey University 䊲

Frank P. Deane University of Wollongong 䊲

Kevin R. Ronan Massey University Despite the emphasis of homework assignments in psychotherapy research and practice, methods to assess homework compliance have been relatively neglected. This article presents a brief review of 32 studies that described the assessment of homework compliance, and evaluated homework compliance in relation to treatment outcome. More than half of the studies relied on a single source of compliance data (n ⫽ 23), eight studies involved retrospective accounts, and only four studies used the same measure of homework compliance. The vast majority of studies focused on the assessment of “homework compliance” without consideration of the “quality of homework completion” or other key factors. A more comprehensive framework for homework compliance is discussed, and a new Homework Rating Scale (HRS) is proposed as the first step towards assisting the field in a more reliable and valid assessment of homework compliance. © 2004 Wiley Periodicals, Inc. J Clin Psychol 60: 627–641, 2004. Keywords: homework assignments; homework; compliance; assessment; clinical practice

Nikolaos Kazantzis, School of Psychology (Albany Campus) and Waitemata District Health Board Cognitive Therapy Center; Frank P. Deane, Department of Psychology and Illawarra Institute for Mental Health; Kevin R. Ronan, School of Psychology (Palmerston North Campus). The authors thank Michael E. Addis, Michael J. Bryant, David D. Burns, Keith S. Dobson, Irene Elkin, Mike Startup, and Michael Tompkins for helpful discussions on the methodological issues surrounding the assessment of compliance (or adherence) in psychotherapy. Preparation of this article was supported in part by Massey University Research Award PR56786.1207 MURF to Nikolaos Kazantzis. Correspondence concerning this article should be addressed to: Nikolaos Kazantzis, Ph.D., School of Psychology, Massey University at Albany, Private Bag 102904, NSMC, Auckland, New Zealand; e-mail: [email protected]

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 60(6), 627–641 (2004) © 2004 Wiley Periodicals, Inc. Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.10239

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Homework assignments have received emphasis as a core and crucial component of psychotherapy for several decades (cf. Beck, Rush, Shaw, & Emery, 1979), and can be traced back to early behavioral and cognitive treatment formulations (e.g., Herzberg, 1941; Kanfer & Phillips, 1966; Kelly, 1955). Within the Beckian approach, therapists systematically assign homework assignments that correspond with their individualized conceptualization of the client’s presentation, the relevant empirically supported cognitive model, and its associated treatment interventions. These accounts of integrating homework into therapy have been extended in several recommendations for research and practice (e.g., Detweiler & Whisman, 1999; Persons, 1989; Shelton & Levy, 1981a) as well as in clinical discussions among prominent researcher-practitioners in the field (see the special issue of the Journal of Clinical Psychology, Kazantzis & Lampropoulos, 2002). In addition, there is a beginning theoretical work on the use of homework as a common process for promoting change in the range of psychotherapy approaches (see the special issue of the Journal of Psychotherapy Integration, Kazantzis & Ronan, in press). A long line of empirical investigations has clearly demonstrated a causal link between the inclusion of homework assignments and improved treatment outcome (for a review, see Kazantzis, Deane, & Ronan, 2000) as well as a correlational link between client compliance with homework and outcome (Burns & Spangler, 2000; Kazantzis, Ronan, & Deane, 2001). Research has sought to examine more specific aspects of the process of integrating homework into therapy, such as the effect of matching the type and difficulty of homework activity assigned with the client’s presenting problem (Conoley, Padula, Payton, & Daniels, 1994; Mahrer, Nordin, & Miller, 1995) as well as the relationships between therapist competence in assigning homework, homework compliance, and treatment outcome (e.g., Bryant, Simons, & Thase, 1999; Shaw et al., 1999). Although homework assignments continue to be the focus of clinical research and practice (e.g., Abramowitz, Franklin, Zoellner, & DiBernardo, 2002; Woody & Adessky, 2002), actual methods of assessing client completion of homework, or compliance, have been relatively neglected. An early survey of the treatment-outcome literature reported that 95% of studies before 1980 failed to include a measure of homework compliance even though homework featured as a core component of the treatments under investigation (Shelton & Levy, 1981b). In more recent times, psychotherapy researchers have emphasized the limitations in contemporary methods of homework compliance assessment, and have called for more innovative assessment practices (Burns & Spangler, 2001; Kazantzis et al., 2001). However, with few exceptions (e.g., Schmidt & WoolawayBickel, 2000), assessment methods have remained largely unchanged in their focus on the “quantity of homework compliance” as opposed to “quality of homework compliance” over the past two decades (see early critique in Primakoff, Epstein, & Covi, 1986). As this article will outline, the assessment of homework compliance has been a significant shortcoming in research on this feature of psychotherapy process. This article describes key advances as well as some continuing problems in the assessment of homework compliance. Based on published outcome studies, this article presents a brief review of existing assessment methods, and then extends this discussion by presenting recommendations for clinical practice in the form of a new measure of homework compliance.

Brief Review of Homework Compliance Measures We restricted our review of the literature to studies that described the assessment of homework compliance, and quantitatively evaluated compliance to treatment

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outcome 1 . More specifically, studies examining homework effects were identified using three methods: (a) a computer search of the PsychINFO database 1980 through 2002 using the key terms behavioral practice, extratherapy, extratreatment, home practice, homework, and self-help assignments; (b) a manual search of the reference sections of previous reviews; and (c) a manual search of the reference sections of studies examining the relationship between homework (or homework compliance) and therapy outcome. This search strategy incorporated the same key terms and criteria as that used for a metaanalysis of the homework literature (e.g., Kazantzis et al., 2000). As we were interested in presenting a representative description of the homework compliance measures used in psychotherapy research, those studies that reported re-analyses of previously published datasets using the same compliance measures (e.g., Burns & Spangler, 2000; Lax, Basoglu, & Marks, 1992) were excluded to prevent unwarranted duplication in the review. The final sample of studies (N ⫽ 32) is summarized in Table 1. Source and Timing of Compliance Assessment Table 1 shows the sample size, homework type, and compliance assessment methods for studies included in the review.2 As the majority of the studies of homework effects concentrated on either anxiety or depression (34% and 38%, respectively), studies were grouped into these categories in contrast to a third “general outpatient” category for presentation in the table. More than half of the studies relied exclusively on a single source of compliance data (n ⫽ 23, 72%). Of the studies using multiple sources of homework compliance data (n ⫽ 9, 28%), four studies involved client and therapist data, three involved objective and client data, and only one study involved a comparison to independent compliance assessment. In terms of the timing of homework compliance assessment, 23 studies (72%) reported that compliance assessment was conducted either session by session, daily, or in real time. Eight studies (23%) involved retrospective accounts. Measures of Compliance Only four studies used the same measure of homework compliance (e.g., Abramowitz et al., 2002; Bryant et al., 1999; Leung & Heimberg, 1996; Woody & Adessky, 2002). These investigations used a single item rated on a scale of 0 (the patient did not attempt the assigned homework) to 6 (the patient did more of assigned homework than was requested ) originally proposed in the review by Primakoff et al. (1986). Single-item global ratings of homework compliance were the most consistently used format for homework compliance assessment (n ⫽ 12, 38% of all studies). Three studies incorporated objective measures to assess compliance with betweensession relaxation practice. More specifically, two studies described the attachment of a cumulative timing device within the sealed battery compartment of a commercially available portable cassette recorder (e.g., Hoelscher, Lichstein, & Rosenthal, 1984, 1986). However, the third study used a more elaborate method involving a relaxation audiotape 1

The literature concerning the assessment of pharmacological treatments was not covered. The only data sources that required some judgment in creating Table 1 were the estimates of homework compliance based on therapist ratings of client records (e.g., thought diary, activity scheduling). In these instances, the data source was classified as a therapist rating of compliance because therapists were required to assess client compliance from records originally obtained for self-monitoring purposes (i.e., to provide “objective” data about the client’s problems). 2

28

28 48

Abramowitz et al. (2002)

Barlow et al. (1984) Edelman & Chambless (1993)

159

Burns & Nolen-Hoeksema (1991)

34 8 22 59 35 20 40 12

14 175

Bryant et al. (1999) Burns & Nolen-Hoeksema (1992)

Fennell & Teasdale (1987) Harmon et al. (1980) Kornblith et al. (1983) Neimeyer & Feixas (1990) Persons et al. (1988) Startup & Edmonds (1994) Thompson & Gallagher (1984) Zettle & Hayes (1987)

150

Sample Size a

Addis & Jacobson (2000)

Study

40 –

35.2

– – – 46.5 37.5 41.8 67 41.5

36.6

37.4 36.1

37.9

Average Age b

ns ns

ns

Source

Therapist –

ANXIETY f Therapist

Independent Client Therapist Client Therapist Independent Therapist Therapist Therapist Therapist Therapist Client –

DEPRESSION d Therapist

Bibliotherapy e Thought record ns ns ns ns ns ns

ns

ns ns

ns

Homework Type

Table 1 Detail on Homework Compliance Assessment Methods in Homework Research

Session-by-session –

Retrospective

Sessions 1–3 Sessions 4– 6 Session-by-session Retrospective Retrospective Retrospective Retrospective Session-by-session Daily Session-by-session Session-by-session Retrospective Session-by-session Retrospective –

Frequency

Client record –

Single item 7-point scale

Single item 3-point scale Single item 3-point scale Single item 7-point scale Single item 5-point scale Single item 5-point scale Single item 5-point scale Single item 5-point scale Client record Client record – – Single dichotomous rating Single item 7-point scale Self-report –

Instrument

Homework Compliance Assessment

3.56 exposure 3.30 monitoring 2.46 times/week –

0.43 0.54 4.01 3.28 3.47 – – – – 55% of time – – 4.59 – –

Average Rate c

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26 16 67 24 40 53

46

27 76 36 34

32

15 64

23

Jannoun et al. (1980) Jannoun et al. (1982) Leung & Heimberg (1996) Marks et al. (1988) Solyom et al. (1981) Woody & Adessky (2002)

Blanchard, Nicholson, Radnitz, et al. (1991)

Blanchard, Nicholson, Taylor, et al. (1991) Gasman (1992) Hawton et al. (1992) Hoelscher et al. (1986)

Holtzworth-Munroe et al. (1989)

Ingram & Salzberg (1990) Kazdin & Mascitelli (1982)

Taylor et al. (1983)



31.9 30.4

41.4

33.6 – 41 51.1

39.2

32 36 35.8 – 32 33

– 36.7

Therapist Objective Client Therapist Therapist Therapist Therapist Therapist Therapist

Relaxation

Assertion i Exposure

ns

Relaxation Video h Exposure Relaxation

Independent Client Therapist Objective Client Therapist Client Independent Client Therapist Objective Client

GENERAL OUTPATIENT g Biofeedback Therapist

Exposure Relaxation ns Exposure Exposure ns

ns Relaxation

Daily Retrospective Retrospective Retrospective At Session 3 Real time Daily Session-by-session Session-by-session Session-by-session Session-by-session Session-by-session Real time Daily

Session-by-session Real time Daily Daily Daily Session-by-session Session-by-session Daily Session-by-session

Client record Interview Interview 2 items in questionnaire Single item 5-point scale Electronic device Client record Single item 9-point scale Single item 9-point scale Client record Single item 7-point scale Interview Electronic device Client record

– Electronic device Client record Client record Client record Single item 7-point scale Client record Client record Single item 7-point scale

– – – 49% complied – 100 min/week 120 min/week – – 12.1 times/week – 94.1% complied 4.6 times/week 5.9 times/week

– 68.2 min/week 105.2 min/week – – – – – 4.64 start of tx 4.25 end of tx

Note. ns ⫽ No single type of homework activity in treatment. a Sample size involved in analysis of the homework-related effect. b Average age of homework group where experimental methodology is employed and overall sample value not reported. c Values mean scores on rating scales except where otherwise stated. d n ⫽ 12. e Reading the memo by Beck and Greenberg (1974). f n ⫽ 11. g n ⫽ 9. h Videotape of therapy session. i Six assertive techniques from Smith (1975) and a seventh involving expression of positive feelings.

52 20

Edelman & Chambless (1995) Hoelscher et al. (1984)

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superimposed with 60-Hz sounds at regular intervals, a microphone, an event counter, and playback device that recorded the number of 60-HZ sounds occurring between therapy (Taylor, Agras, Schneider, & Allen, 1983). Although these objective measures were intended to be more accurate in their measurement of compliance, they were able only to estimate the amount of time clients spent playing audiotapes, and provided no information on the quality of the learning experience for clients. As Hoelscher et al. (1984) noted, clients may have suspected that the equipment incorporated a hidden measurement device and simply left the audiotape player running. Rate of Compliance The inconsistency in the measurement of homework compliance is reflected in the data these measures have produced. Of those studies reporting the rate of compliance (n ⫽ 13), one study reported that 49% of the sample “made video homework a regular part of therapy” (Gasman, 1992, p. 94), one study reported that 94% of the sample “had practiced [homework] after each of the sessions” (Kazdin & Mascitelli, 1982, p. 253), and one reported that self-report data indicated that clients had “accurately completed the [homework] assignments” 55% of the time (Kornblith, Rehm, O’Hara, & Lamparski, 1983, p. 519). Studies that obtained a weekly estimate of compliance (n ⫽ 3) reported average rates ranging from 2.5 times per week to 12 times per week (Barlow, O’Brien, & Last, 1984; Ingram & Salzberg, 1990; Taylor et al., 1983). Studies that obtained a weekly estimate of time spent on homework per week (n ⫽ 2) reported rates ranging from 68 min per week to 120 min per week (Hoelscher et al., 1984, 1986). Studies that used the same single-item rating scale either reported an average rate of compliance overall (i.e., Bryant et al., 1999), average rates of compliance for different homework assignments (i.e., Abramowitz et al., 2002), rates of compliance for all homework assignments at the beginning and the end of treatment (i.e., Woody & Adessky, 2002), or did not report the rate of compliance (i.e., Leung & Heimberg, 1996). Consequently, the diversity of assessment methods and the resultant data restricts any meaningful interpretation of compliance rates across studies. Summary and Conclusions from the Review With one exception (i.e., Schmidt & Woolaway-Bickel, 2000), all studies in this review focused on the assessment of quantity (or extent) of homework compliance rather than the quality of learning. This is surprising given that proponents of homework have traditionally emphasized that partial homework completion, and even noncompletion, can often provide the therapist with useful information for the conceptualization and treatment plan (Beck et al., 1979). At the same time, only a small handful of studies used the same measure of homework compliance, making any comparisons between studies decidedly problematic. Therefore, our first conclusion was that the assessment of homework compliance has been a significant shortcoming in psychotherapy research. Lack of standardization in the measurement of compliance, reliance on single-item global measures, and the confounded constructs of quantity and quality suggest that there is a need for a new measure that takes account of these limitations. There also are limitations with the way in which homework compliance measures have been utilized to evaluate therapy process. Homework compliance was most commonly assessed using one source of data, with only a small proportion of studies directly comparing two or more sources of data. Contemporary reviews of psychotherapy research

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emphasize the importance of incorporating both client and therapist perspectives when studying therapy processes (Orlinsky, Rønnestad, & Willitzki, 2004), and the metaanalysis of the homework research provided evidence to suggest that homework effects were moderated by the source of compliance data (Kazantzis et al., 2000). In addition, a sizable proportion of studies used retrospective accounts of homework compliance obtained at posttreatment or during follow-up assessments. Retrospective ratings are clearly problematic, as clients who have experienced improvement in symptoms may inadvertently inflate the extent to which they complied with homework. Alternatively, measuring compliance retrospectively may miss the early, rapid recovery that has been hypothesized to occur in response to homework completion (e.g., Persons, Burns, & Perloff, 1988). The Kazantzis et al. (2000) meta-analysis provided further evidence to suggest that the timing of compliance data moderates homework effects. Therefore, our second conclusion was that future research studies should consider the value of assessing homework compliance from multiple sources and assess compliance regularly throughout therapy as a means of adjusting the course of therapy for the individual client. Such data on homework completion from the beginning stages of therapy would have valuable implications for both research and practice (see discussion in Lambert et al., 2003).

Recommendations for Clinical Practice Many of the studies included in the previous review do not necessarily provide the level of detail necessary for guiding clinical practice. For example, it is difficult to know what a practitioner could conclude from the 12 studies examining homework compliance within treatments for depression. The information reported in Table 1 is unlikely to be helpful for deciding how to proceed with a depressed client who has learned how to schedule activities to increase his or her sense of pleasure and mastery, but who is unable or unwilling to attempt completion of a thought record. The theoretical basis for using homework assignments rests firmly on the behavioral principle of generalization, but there is no theoretical model that considers the features of the individual client, therapist factors, and features of the homework assignment as a means of maximizing client learning through the completion of homework. Numerous practice recommendations have appeared in the literature (e.g., Persons, Davidson, & Tompkins, 2001), but these have typically echoed the clinical guidelines outlined in early psychotherapy texts outlining the use of homework in therapy (e.g., Beck et al., 1979). A theoretical model that considers client, therapist, and task characteristics would serve as a firm foundation upon which to develop more extensive methods of homework compliance assessment. In an attempt to assist the field in understanding the construct of homework compliance, Detweiler and Whisman (1999) proposed a “heuristic” or framework based on findings from the research literature. Within the Detweiler and Whisman framework, various client factors (e.g., collaborative involvement in setting homework, having clear rationale for homework completion, obtaining enjoyment from task), therapist factors (e.g., persuasiveness/enthusiasm, specificity in therapists’ administration of task), and task characteristics (e.g., difficulty level, written reminders) were hypothesized to be necessary precursors to client compliance with homework activities. Prior attempts to explain homework compliance have focused almost exclusively on therapist behaviors in reviewing, designing, and assigning homework (e.g., Shelton & Levy, 1981b) or have not intended to provide a guiding theory for research and practice (e.g., Carich, 1990; Halligan, 1995).

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Therefore, our recommendations for practice will follow the Detweiler and Whisman (1999) framework as a guiding foundation. These recommendations are then reflected in the items in our new homework compliance measure for use in clinical practice. Homework Rating Scale As the first step towards assisting the field in the development of more reliable and valid measures of homework compliance, we offer a Homework Rating Scale (HRS) as a tool for clinical practice (see Appendix). Although the HRS may later demonstrate utility as a measure for studying psychotherapy process, the absence of existing psychometric data limits our recommendations for its use to the clinical practice setting. The HRS is a 12-item, client self-report measure designed to measure client, therapist, and task characteristics associated with client compliance with homework assignments. Unlike existing measures discussed in this review, it separates the construct of compliance into two components, quantity and quality, asking clients to rate these on a 5-point scale. The theoretical and empirical rationale for the remaining items in the HRS is outlined below, together with comments regarding the clinical utility of client responses. Client Factors A series of client factors have been suggested to be important in determining client completion of homework assignments. While any homework assignment should be discussed so that the client has a clear understanding and involvement in setting the homework activity, there may be several reasons why this is not always achieved. Some authors have noted that practical obstacles in the client’s environment can sometimes interfere with homework completion despite attempts to identify them in-session (Beck et al., 1979; Shelton & Levy, 1981b). The homework activity also may be more difficult than the client and therapist anticipated, and may extend beyond the client’s ability or skill level (Beck et al., 1979). It also is suggested that clients will be more likely to enjoy activities that they are involved in designing (Detweiler & Whisman, 1999; Wankel, 1993). Perhaps most importantly, the client may present with attitudes, rules, or beliefs about the homework activity which may (or may not) be characteristic of their presenting problems, but still serve to interfere with the opportunity to learn from homework assignments. These features of the client’s presentation may be related to the severity of the presenting problems, personal responsibility for change, or the efficacy of the treatment being offered (Shelton & Levy, 1981b). For example, the client also may exhibit a belief (or schema) structure that promotes noncompletion of homework such as unrelenting standards, fear of failure, or increased sense of social desirability (Persons, 1989). These cognitive features may occur independently or in combination with negative beliefs about the future, the world, and other people—including the therapist (Burns & Auerbach, 1992; Goisman, 1985). Even though these client factors are grounded in theory and clinical experience, there is limited empirical support in the existing literature. Research has sought to relate severity and type of presenting problem to homework compliance, without success (e.g., Bryant et al., 1999; Leung & Heimberg, 1996; Worthington, 1986). Similarly, willingness to engage in therapy and acceptance of a rationale for cognitive-behavioral therapy have not been linked with homework compliance (e.g., Addis & Jacobson, 2000; Burns & NolenHoeksema, 1991). Given the limitations of the homework compliance measures in this

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area of research, it is simply possible that the source, timing, or methods of compliance assessment were insufficiently sensitive to detect the relationship between client factors and completion of homework assignments. Nonetheless, practitioners can attend to these factors when integrating homework assignments into therapy through in-session discussion with clients. We have designed five items on the HRS to target client factors. These items ask the client to rate the extent to which practical obstacles interfered with the assignment (Item 4), how well they understood what was involved (Item 5), how well they understood the rationale for the assignment (Item 6), their perceived involvement in planning the assignment (Item 7), and how much they enjoyed the assignment (Item 10). We have found it useful to ask clients to complete these items on a semiregular basis in the waiting room before a therapy session, to be discussed as part of reviewing homework.3 Aside from saving time, client responses on these items often function as a way of prioritizing the barriers to the effective use of homework in therapy. Finally, we would like to highlight the client’s age as an important factor. The population of older adults is growing worldwide, and the empirical support for homework effects within cognitive-behavioral therapies for older adults is emerging (e.g., Coon & Thompson, 2003). We suggest that practitioners consider the appropriateness of their use of homework and revise measures such as the HRS accordingly. Although a detailed consideration of the special issues in assessing homework compliance for different age groups is beyond the scope of this article, discussion of these clinical issues has been published elsewhere (see Kazantzis, Pachana, & Secker, 2003). Therapist Factors A series of therapist factors also have been suggested to be important in predicting whether a client will complete a given homework assignment. Homework should be reviewed and summarized at the beginning of every session, be presented with a rationale that is understood by the client, and be tailored to the client’s specific problems (Beck et al., 1979). At the same time, therapists should problem solve difficulties that could or did prevent learning from homework assignment completion. To maximize this problem-solving process and ensure the assignment is practically possible given the demands on the client’s time, therapists can work towards a high degree of specificity in setting up the homework. That is, therapists can collaboratively work with the client to decide when, where, how often, and how long the homework assignment is likely to take (Shelton & Levy, 1981b). Several studies have sought to examine therapist factors in relation to homework compliance, but the results have been mixed. In two studies of therapist competency in delivering cognitive-behavior therapy for depression, therapists’ competency in the review of homework assignments was correlated with homework compliance (e.g., Bryant et al., 1999; Shaw et al., 1999; also see Worthington, 1986). However, a study by Startup and Edmonds (1994) did not find any evidence to suggest that therapist adherence to the homework administration procedures was associated with compliance. Similarly, a study by Burns and Nolen-Hoeksema (1992) did not produce a significant relationship between therapist empathy and compliance. Again, the limitations in homework compliance assessment together with the limitation of low statistical power in this research (see Kazantzis, 3 Although we use this measure on a semiregular basis in our clinical work, we have not yet gathered sufficient data for preliminary psychometric analysis of the HRS. The limited data have been collected solely for clinical purposes, and our clients have not provided informed consent for its use in publications or research. As noted in the final summary and conclusion of this article, the HRS will form the focus of psychometric evaluation in our programmatic research.

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2000) are likely explanations for the inconsistencies in these results. In the counseling literature, however, there is promising evidence to suggest that activities are more likely to be completed between sessions when they match with client goals for treatment (Conoley et al., 1994). Both in designing and reviewing homework, we have found it helpful to ask clients for their views on the degree to which the homework assignment was specific and matched their therapy goals. Consequently, we have designed two items on the HRS to target two key areas of therapist competence. These items ask clients to rate the extent to which the guidelines for the homework assignment were specific (Item 8) and matched their goals for therapy (Item 9). Responses on these items can often reveal gaps in the planning or “setup” for the learning assignment, both in terms of the practical considerations for its completion and clients’ view of its relevance. Task Characteristics Finally, the difficulty of the homework task has been suggested to be important in predicting whether a client will complete a given homework assignment. This assertion is centered on the importance of ensuring that the difficulty level of the assignment is tailored and matched to the ability of the client, and has preliminary empirical support (Conoley et al., 1994; Worthington, 1986). In reviewing homework, we have found it consistently helpful to ask clients how difficult they found the assignment. Following the discussion on difficulty, we also have found it helpful to ask clients for their view on whether the particular assignment has promoted any learning or progress towards their therapy goals. As a result, we designed the three remaining items on the HRS to target this and other task factors. These items ask the client to rate how difficult the assignment was (Item 3), the extent to which the homework helped them gain control over their problems (Item 11), and whether it helped with progress in therapy (Item 12). Client responses to these questions, either on the HRS or in verbal discussion, also provide the therapist with an indication on the extent to which a client is ready to progress to new skills or components of the treatment. Summary and Conclusion The issue of how best to assess homework compliance remains an empirical question. Taking into account the theoretical and empirical evidence to date, we have compiled a new measure for homework compliance assessment that clinicians can use in their everyday practice. The HRS is more extensive than existing measures of homework compliance, both in terms of the number of items and measurement of several theoretically based dimensions of clients’ compliance with learning activities completed as homework assignments. The measure itself will be undergoing examination in our own programmatic research and used on a semiregular basis in our own practices. In terms of research, one avenue worth exploring is the extent to which the degree of therapist competence in assigning homework (i.e., collaborating with the client, specification of when, where, how often, and how long) is linked with client learning through homework completion. For example, does a client’s mastery of a homework activity relate to the quality of planning, increased specificity, and the explicit linking of homework activities to treatment goals? Furthermore, does a sense of mastery or progress through the completion of homework assignments early in therapy predict subsequent outcome? Answers to such questions will clarify the role of homework assignments in promoting positive therapy outcomes for clients.

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Appendix

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References References marked with an asterisk were included in the review. *Abramowitz, J.S., Franklin, M.E., Zoellner, L.A., & DiBernardo, C.L. (2002). Treatment compliance and outcome in obsessive-compulsive disorder. Behavior Modification, 26, 447– 463. *Addis, M.E., & Jacobson, N.S. (2000). A closer look at the treatment rationale and homework compliance in cognitive behavioral therapy for depression. Cognitive Therapy and Research, 24, 313–326. *Barlow, D.H., O’Brien, G.T., & Last, C.G. (1984). Couples treatment of agoraphobia. Behavior Therapy, 15, 41–58. Beck, A.T., & Greenberg, R.L. (1974). Coping with depression. New York: Institute for Rational Living. Beck, A.T., Rush, J.A., Shaw, B.F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford Press. *Blanchard, E.B., Nicholson, N.L., Radnitz, C.L., Steffek, B.D., Appelbaum, K.A., & Dentinger, M.P. (1991). The role of home practice in thermal biofeedback. Journal of Consulting and Clinical Psychology, 59, 507–512. *Blanchard, E.B., Nicholson, N.L., Taylor, A.E., Steffek, B.D., Radnitz, C.L., & Appelbaum, K.A. (1991). The role of regular home practice in the relaxation treatment of tension headache. Journal of Consulting and Clinical Psychology, 59, 467– 470. *Bryant, M.J., Simons, A.D., & Thase, M.E. (1999). Therapist skill and patient variables in homework compliance: Controlling an uncontrolled variable in cognitive therapy outcome research. Cognitive Therapy and Research, 23, 381–399. Burns, D.D., & Auerbach, A.H. (1992). Does homework compliance enhance recovery from depression? Psychiatric Annals, 22, 464– 469. *Burns, D.D., & Nolen-Hoeksema, S. (1991). Coping styles, homework compliance, and the effectiveness of cognitive behavioral therapy. Journal of Consulting and Clinical Psychology, 59, 305–311. *Burns, D.D., & Nolen-Hoeksema, S. (1992). Therapist empathy and recovery from depression in cognitive behavioral therapy: A structural equation model. Journal of Consulting and Clinical Psychology, 60, 441– 449. Burns, D.D., & Spangler, D. (2000). Does psychotherapy homework lead to changes in depression in cognitive behavioral therapy? Or does clinical improvement lead to homework compliance? Journal of Consulting and Clinical Psychology, 68, 46–56. Burns, D.D., & Spangler, D.L. (2001). Can we confirm our theories? Can we measure causal effects? Reply to Kazantzis et al. (2001). Journal of Consulting and Clinical Psychology, 69, 1084–1086. Carich, M.S. (1990). Utilizing task assignments within Adlerian therapy. Individual Psychology, 46, 217–224. Conoley, C.W., Padula, M.A., Payton, D.S., & Daniels, J.A. (1994). Predictors of client implementation of counselor recommendations: Match with problem, difficulty level, and building on client strengths. Journal of Counseling Psychology, 41, 3–7. 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 Psychiatry, 11, 53– 61. Detweiler, J.B., & Whisman, M.A. (1999). The role of homework assignments in cognitive therapy for depression: Potential methods for enhancing adherence. Clinical Psychology: Science and Practice, 6, 267–282. *Edelman, R.E., & Chambless, D.L. (1993). Compliance during sessions and homework in exposurebased treatment of agoraphobia. Behavior Research and Therapy, 31, 767–773.

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