Guidelines for enhancing homework compliance - Wiley Online Library

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The ability to enhance compliance with therapeutic tasks such as home- ... Compliance with a homework assignment is defined here as the client carrying out.
Guidelines for Enhancing Homework Compliance 䊲

Michael A. Tompkins San Francisco Bay Area Center for Cognitive Therapy and University of California, Berkeley

The ability to enhance compliance with therapeutic tasks such as homework may be a crucial therapeutic skill that determines the success of psychotherapy in real-world clinical settings. This article presents guidelines for enhancing homework compliance through careful attention to: features of homework assignments, such as whether they are meaningful and doable and include a clear rationale and backup plan; and the therapist’s manner when developing and reviewing homework assignments, such as whether that therapist is curious, collaborative, and reinforces all behavior that supports the homework’s purposes. Clinical examples are used to illustrate the application of the guidelines. © 2002 Wiley Periodicals, Inc. J Clin Psychol/In Session 58: 565–576, 2002 Keywords: homework; nonadherence

compliance;

noncompliance;

adherence;

Personally, I am always ready to learn, although I do not always like being taught. —Winston Churchill

Therapists’ growing interest in briefer forms of psychotherapy has popularized the use of homework assignments. Most psychologists now report that they use homework assignments in their clinical work (Kazantzis & Deane, 1999) and consider homework or selfhelp assignments to be a significant area of growth in psychotherapy research and practice (Norcross, Alford, & DeMichele, 1992). Nonetheless, most clinicians who assign homework know that clients do not always do it, or do it well, and that much of the clinical work with some clients centers on improving their compliance with structured tasks such as homework. Indeed, the ability to enhance and manage compliance with therapeutic tasks such as homework may be a crucial therapeutic skill that determines the success of psychotherapy in real-world clinical settings (Addis & Jacobson, 2000). Compliance with a homework assignment is defined here as the client carrying out the assignment in the manner agreed upon. Three general factors may contribute to homeCorrespondence and requests for reprints should be sent to: San Francisco Bay Area Center for Cognitive Therapy, 5435 College Ave., Ste. 108, Oakland, CA 94618-1502. Telephone: 510-652-4455, extension 12; fax: 510-653-9453; e-mail: [email protected].

JCLP/In Session: Psychotherapy in Practice, Vol. 58(5), 565–576 (2002) © 2002 Wiley Periodicals, Inc. Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.10033

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work noncompliance: task factors, therapist factors, and client factors (Detweiler & Whisman, 1999). Task factors concern particular features of homework assignments that increase the likelihood that the client can carry them out, such as whether the homework assignment is described clearly and concretely and is doable according to the client’s given level of functioning. Therapist factors concern the features of the therapist’s manner that can increase the likelihood that the client will carry out a homework assignment, such as whether the therapist is able to develop and maintain a positive therapeutic alliance and can effectively reinforce homework compliance. Client factors concern certain psychological variables that can decrease the likelihood that clients will follow through with structured tasks such as homework. Often these are the same psychological variables responsible for problems in the clients lives in general and may be the reason they sought treatment in the first place. Typically, therapists have far more control over the homework assignment and their manner with clients than over the clients particular psychological variables. For this reason, it makes sense that therapists take as much care as possible when setting up homework assignments so that most clients, regardless of variables, can complete them. Similarly, it makes sense that therapists strive to maintain a manner with clients that (all things being equal) will be likely to enhance compliance with homework assignments in most cases. This article presents guidelines designed to enhance homework compliance, through careful attention to features of homework assignments and of therapists manner when they develop and review homework. The guidelines are largely based on clinical experience rather than empirical research. However, many of the guidelines, such as beginning therapy with small homework assignments (graded task assignments), are included in empirically validated treatments such as cognitive therapy for depression (Beck, Rush, Shaw, & Emery, 1979). In addition, other guidelines, such as reinforcing pro-homework behavior, are evident in the well-established literature on operant conditioning and behavior therapy (Shelton & Levy, 1981). Finally, the author has tried to take a trans-theoretical approach to homework. When possible, specific interventions unique to a particular psychotherapy, such as the use of thought records in cognitive behavior therapy, have been avoided. However, because the author is a cognitive behavior therapist, he may hold assumptions about the structure and process of therapy, including homework, that others with different theoretical orientations do not share. He hopes that the reader can look past these assumptions to see homework as a useful element to most therapies and decide that homework is worth a try. Features of the Homework Assignment Homework Assignments Are Meaningful The client is more likely to comply with a homework assignment if it is meaningful to him or her. By meaningful, I mean a homework assignment that makes sense on several levels: The homework must be relevant to the central goals of therapy; relevant to the focus of the therapy session from which the homework is drawn; agreeable to client and therapist; and appropriate to the client’s sociocultural context. Meaningful Homework Assignments Are Relevant to the Central Goals of Therapy Clients generally enter therapy with some idea about what they want to achieve. If the client’s goal is to become less depressed, then it must make sense to the client how a

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particular homework assignment will help get him or her there. The first step, therefore, in devising a homework assignment is to start with clear and realistic treatment goals. Once treatment goals have been identified and agreed upon, the therapist can refer back to the goals when discussing with the client a particular assignment’s meaningfulness by saying, “Gloria, I think getting out of the house some this week would be a great homework assignment for you, and we’ll talk about the specifics of that in a minute. Right now I want to remind you that getting out of the house a bit more is an important strategy to help you feel less depressed, which was a goal you set for yourself at the beginning of your therapy. So this isn’t just about you getting out more; this is about you learning and practicing another strategy to help yourself feel less depressed now and when you’re feeling down in the future.” In this way, the therapist underscores for Gloria that the homework assignment is consistent with her overarching goal to manage her depression, thereby not only increasing the likelihood that she will complete the particular homework assignment but will complete other therapeutic tasks as well.

Meaningful Homework Assignments Are Salient to the Focus of the Session The client who experiences homework assignments as coming out of the blue may feel that the therapist is not listening. The client may then be less willing to try an assignment because he or she isn’t confident that the therapist understands the problem. The best assignments emerge easily from the content and focus of the session. To help with this, the therapist can follow five steps. Step 1—Summarize for the client what was discussed or worked on in the therapy session. Because therapy material is often highly charged, the client may have difficulty concentrating or tracking the content of the session. At such times, the therapist risks introducing a homework assignment that may appear irrelevant to the client. Summaries help in this regard and are useful at other points during the session (Beck, 1995; Persons, Davidson, & Tompkins, 2001). Step 2—When appropriate, link the focus of this session to previous sessions when the problem has been discussed and worked on. This is particularly true for homework that is directed at problems occurring repeatedly in a variety of situations. This kind of bridging statement not only reinforces the homework’s relevance to the problem at hand but also provides a focus and sense of continuity to the entire therapy. Step 3—Link the session summary to the homework assignment. In particular, link the summary’s main point to the assignment and remind the client that the homework is an opportunity to work on the problem. For example, the therapist might say, “It sounds like you were very angry following the meeting with your boss. I’m thinking that a homework assignment that helped us understand why you get so angry when you interact with your boss might help us work on this anger problem. What do you think?” Step 4—Link the recommended homework assignment to the client’s treatment goals. In this way, the therapist strengthens the link between the homework and the reason the client sought help to begin with. The best assignments link clearly to the client’s treatment goals. Such a linkage takes advantage of the motivation the client has for working on the problems that are the most troubling, therefore increasing the likelihood that the client will try the homework. Step 5—Check that the homework assignment makes sense to the client given what has been discussed and worked on in the session. I recommend that the therapist ask the client to tell why this assignment is being recommended at this particular time, with the therapist making a statement like, “George, we’ve focused on your difficulty being assert-

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ive with people in authority, like your boss. Perhaps you could tell me why you think the homework assignment I’m suggesting might help you with this problem.” When the client correctly summarizes the assignment’s problem and rationale, the therapist should praise and congratulate him or her. If the summary is not quite on the mark, the therapist should reinforce the client’s approximations and then repeat the process until certain that the client understands the assignment’s rationale and agrees that the assignment is meaningful to both parties. The therapist should not assign homework that the client does not see as meaningful. Instead, the therapist should work with the client until the assignment becomes meaningful or develop with the client another assignment that is. Meaningful Homework Assignments Are Agreeable to the Therapist and Client It is essential that the client agree that there is value to a homework assignment. The therapist should always check with the client to see if the assignment makes sense and if the client is willing to try it; the therapist should not wait until the end of the session to discuss an assignment’s value. Instead, the issue should be raised early and often during the session so that there is ample time to discuss the client’s possible reservations or misunderstandings. More than once, the therapist has assigned a task that the client didn’t agree to try. A simple “Would you be willing to try this?” may do, but the therapist should not be surprised upon hearing “No.” It is important that assignments are mutually agreeable, yet this is sometimes difficult. For example, the client may view an assignment as more relevant to the goals of the therapy than the therapist does, which may reflect some disagreement about the goals, including which ones should be the focus of immediate intervention. Substance abuse is a good example: Until client and therapist reconcile disagreement about whether decreasing the client’s substance abuse is an appropriate treatment goal, the client is likely to view homework assignments targeting the substance abuse as meaningless. Also, when it comes to the question of agreement, remember that what is agreeable to client and therapist may not be agreeable to the client’s wife, husband, employer, or primary care physician. The therapist should consult the client to find if he or she anticipates that significant others will disagree that a homework assignment is meaningful or that it addresses the client’s central problems. Meaningful Homework Assignments Are Appropriate to the Client’s Sociocultural Context If an impoverished, depressed single mother with four children is encouraged to engage in more pleasurable activities, such as going to a movie with a friend, without regard to how she will afford not only the movie but the child care and transportation, that homework assignment is doomed from the start. Similarly, an assignment that instructs an Asian American physician who is unhappy with his career to explore other career options in opposition to his family’s wishes and expectations does not appreciate the cultural influences the young man must overcome to engage in such an assignment. The therapist should discuss with the client whether the homework makes sense to them given the client’s particular sociocultural milieu, and if not, alter the assignment so that it is appropriate. For example, a Latino client was taught to preface assertive statements with phrases like “con todo respeto” (“with all due respect”) and to respond to negative reactions to her assertiveness by explaining that she was making the respectful request for the sake of her emotional health rather than for the mainstream American value of “personal rights” (Organista, 1995), which is not a meaningful concept in her culture.

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Homework Assignments Are Doable Doable homework assignments are concrete, specific, and appropriate to the client’s current skill level. Concrete and specific assignments are easier to carry out than vague assignments (Levy & Shelton, 1990; Shelton & Levy, 1981) and include details about when, where, with whom, for how long, and using what materials. A concrete and specific homework assignment might read, “Sit down at your desk at 9 am Monday through Friday and write on your dissertation for 10 minutes each day; use pencil and paper, and disconnect the telephone before beginning to write; and, after you have written for 10 minutes, reward yourself by reading the sports section of the morning newspaper.” In contrast, a vague assignment might read, “Write on your dissertation sometime during the coming week.” A doable assignment also considers the client’s level of functioning. A depressed client who spends the bulk of his day in bed is not likely to spend all day Saturday hiking with friends, even though he thinks he should be able to do this because he did it in the past. Effective homework fosters a sense of mastery only if the client succeeds at it, and it is success that motivates the client to try more. To assess whether an assignment is realistic for the client’s current level of functioning, the therapist can ponder two questions: (1) Is the client doing the assignment now (or some variation of the assignment), and how difficult is it? (2) Has the client done the assignment (or some variation of it) in the past, how long ago was that, and how difficult was it at the time? The therapist can ask the client to rate the task’s difficulty or discomfort on a 10-point scale (10 being most difficult or uncomfortable). Homework Assignments Begin Small It is better to start small and shape approximations to the desired final outcome than it is to insist that clients try tasks that they doubt can be completed. Such graded tasks play a central role in cognitive therapy for depression (by Beck et al., 1979) as well as exposurebased treatments for anxiety disorders. For example, asking a socially anxious client to nod and smile at coworkers, then reinforcing him with praise when he tries it, might open the door for the client to consider other, more challenging homework assignments, like asking a coworker how she spent her weekend. A smaller assignment that the client completes enhances the client’s confidence in the therapist and therapy, strengthening the therapeutic alliance and motivating the client to try more. As a rule, it is best when beginning treatment to start with homework assignments that ask clients to do what they are already doing 30% of the time or more. For example, Cheryl, a 37-year-old woman who sought treatment to help her become more assertive, agreed that homework designed to help her practice her newly learned assertiveness skills made sense. She and her therapist identified several types of people with whom she had trouble being assertive, ranked in order of the percentage of time she was assertive. She and her therapist decided that at first she would try being assertive with Phyllis, a coworker whom she liked and with whom she was able to be assertive 25% of the time. Homework Assignments Have a Clear Rationale Clients are more likely to complete a homework assignment if they understand the reason for doing it. Goldfried and Davison (1976) noted that presenting the client with a general rationale for treatment and explaining the link between the client’s and therapist’s definitions of treatment goals heightens the client’s view that therapeutic tasks such as home-

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work are valid and credible. In addition, a number of studies suggest that clients who agree with a treatment’s rationale improve more rapidly and are more likely to have successful outcomes (Addis & Jacobson, 1996; Fennel & Teasdale, 1987). A homework rationale can be quite simple (“Let’s have you monitor how many panic attacks you have each week so we know how often they occur”) or may involve longer discussions that include analogies, such as viewing problematic beliefs about one’s self as “self-prejudice,” to explain how individuals maintain problematic beliefs about themselves in the face of contradictory evidence (Padesky, 1994; Persons, Davidson, & Tompkins, 2001). The therapist should not assign a homework assignment if the client has not understood and accepted its rationale. Clients who reject a homework rationale may be less open to change (Addis & Jacobson, 2000), perhaps because they are hopeless about anything helping; because they have clear beliefs that the therapist has not explored about what will and will not help solve their problems; or because they don’t understand the rationale. To check whether the client has accepted the rationale, the therapist can ask, “Does the reason I’m recommending the homework assignment make sense to you?” Or, “To what degree does the homework match with your ideas about what needs to change to solve your problem?” (Answers on a 0-to-10 scale are solicited, 10 meaning the homework completely matches the client’s ideas about what needs to change.) Initially the therapist provides the rationale for homework. However, over time, and particularly if a homework assignment is repeated, the therapist can ask the client the reason for an assignment. (“Josh, why do you think it might be a good idea for you to write down each time you smoke a cigarette?”) Not only does this encourage clients to take greater responsibility for designing and implementing their assignments, but it is a good indicator of whether clients understand the homework rationale. Homework Assignments Include a Backup Plan The therapist should spend some time during the session anticipating potential homework obstacles and make a backup plan to handle them. Anticipating obstacles and planning for them increases the likelihood that the client will complete homework assignments. For example, Jason, a depressed auto mechanic, agreed to call George, a friend, later in the day to invite him to go to a movie. At the agreed-upon time, Jason dutifully called George but, when he heard a busy signal, hung up the telephone and did not try again. Had Jason and his therapist planned who Jason might call if he couldn’t reach George, Jason might have completed his homework assignment. There are a number of ways for the therapist to uncover potential homework obstacles. The client can be asked directly (“Do you see any obstacles that would make it hard for you to carry out the assignment?”). The therapist can ask clients if they have tried similar homework assignments in the past and, if so, how they turned out—what problems were encountered? The therapist should be wary if clients qualify answers (“I think that I can handle that if it happens”) or quickly dismiss the therapist’s concerns (“No, there won’t be any problem”); to determine whether the solution is appropriate and doable given clients’ level of functioning, therapists should ask clients how they would handle a typical homework problem. Also, clients could be asked to rate the likelihood (From 0 to 100%, 100% being “highly likely”) that the homework will be done as agreed. Lowpercentage responses can alert the therapist to then explore potential homework obstacles that explain why the client may not do the homework; the therapist can then alter the homework assignment or plan a different assignment altogether, such as monitoring the problem the client is not ready to tackle.

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The therapist can use covert rehearsal (Beck, 1995) to identify obstacles to completing homework assignments. In covert rehearsal, the client is asked to imagine going through all the steps involved in completing the homework assignment by talking aloud to the therapist, who listens for potential obstacles. For example, Betsy, a depressed, unemployed nurse who spent her days in bed, agreed to take a bubble bath as a pleasurable activity to improve her mood and hygiene, which had degraded as a result of her depression. During covert rehearsal, Betsy imagined each step of the process out loud. As she imagined reaching for the bubble bath, she remembered that she had run out of bubble bath several weeks ago. Betsy and her therapist then discussed how and when she would go to the grocery store to buy bubble bath, and this task became her homework assignment. Had Betsy not rehearsed her assignment beforehand, she might have thrown up her hands and gone back to bed when she encountered the empty bubble bath bottle. In addition to identifying what is needed but unavailable, covert rehearsal can be used to identify environmental factors, such as critical relatives, that may decrease homework compliance. Homework Assignments Are Practiced in Session Although it is useful for the client to practice in session every homework assignment before trying it on their own, there are times when in-session homework practice is particularly warranted: (1) when the client lacks the necessary skill and knowledge to do the assignment, (2) when the client tries an assignment for the first time, and (3) when the client is to perform an assignment in the presence of strong emotion. Clients Lack the Necessary Skills and Knowledge. In-session practice enables the therapist to observe whether the client can complete the homework as devised. Peter, a likable but socially anxious young man who wanted to ask more women out on dates, agreed to a homework assignment in which he would introduce himself to a woman at an upcoming wedding he planned to attend. Peter assured the therapist he knew how to appropriately introduce himself to strangers, but when the therapist role-played the situation, Peter stared at the floor while jiggling the change in his pocket and mumbling under his breath, “Hi, I’m Peter. Hi, I’m Peter.” After feedback from his therapist, Peter agreed that further skills training in beginning and maintaining a conversation was needed. Clients Try a Homework Assignment for the First Time. In-session practice is advisable when the client is trying a newly learned skill or response for the first time. For example, the typical response of anxious clients is to avoid what makes them uncomfortable. Such clients are helped by the therapist who models the new response for them (e.g., approach the feared object or situation) and coaches them to practice this response in session: If an arachnophobic client agrees to touch a picture of a spider in a book three times during the coming week, it is best that the therapist have the client look at the picture the entire time while pressing the picture with the full palm of the hand, holding it there for 30 minutes. Clients Are to Perform the Assignment in the Presence of Strong Emotion. In-session practice is particularly helpful when the therapist anticipates that the client will have to perform homework assignments in the presence of intense negative effect, such as fear, anger, guilt, or shame. For example, Ginny, a depressed young attorney who sought help because she had not much of a social life, agreed that she needed to become more com-

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fortable in setting limits with the managing partner, who insisted that she work long hours every weekend. As homework, Ginny agreed to say “no” to the managing partner when he asked her to work the weekend. Ginny practiced the homework assignment with her therapist, who played the role of the managing partner. Ginny did well until the therapist began to turn up the heat by demanding that she work. Eventually Ginny succumbed to her feelings of guilt and gave in to the demands. The therapist stopped the roleplay, praising Ginny for “hanging in there” as long as she did, and reviewed with her the rationale for the homework. The therapist and Ginny then developed a set of adaptive responses she was to read through to help her better tolerate her feelings of guilt. With more practice, Ginny was able to hold her ground in the role plays with her therapist and later with the managing partner. Homework Assignments Include Written Instructions Many clients will be able to remember the details of a homework assignment and follow through with what they have agreed to do. However, it is usually better to formalize these agreements with a set of written homework instructions (Shelton & Ackerman, 1974). Written instructions have been shown to increase compliance with behavioral homework assignments (Cox, Tisdelle, & Culbert, 1988). Written instructions represent a public statement of the client’s intention to comply with the homework, much like a written contract, and also serve as a record of what the client has agreed to do, which can circumvent misunderstandings and disagreements that erode the therapeutic alliance. Lastly, written instructions can help the therapist organize the task of assigning the homework itself. A concrete and explicit format for written homework instructions leads both client and therapist through the main elements of a successful homework assignment and checks whether all elements have been considered and included. Features of the Therapist’s Manner The therapist is an important reinforcer of client behavior: Thus, it is essential for the therapist to maintain a manner when speaking with the client that increases the likelihood that homework will be tried and completed. Therapists can enhance homework compliance if they: (1) are curious, (2) are collaborative, (3) reinforce all pro-homework behavior, (4) emphasize homework completion over outcome, and (5) reinforce successful homework approximations. Be Curious A stance of curiosity rather than firm certainty avoids assumptions, which may lead to misunderstandings that derail attempts to set up or review homework and also may leave the client feeling criticized or put down. Clients always have more information about what contributed to an unsuccessful homework assignment than their therapists, and a curious stance by therapists recognizes and takes advantage of this fact. A curious stance encourages the client to become curious about the homework as well, including the obstacles they may or do encounter and those obstacles’ role in homework noncompliance. Last, but perhaps most important, curious therapists shift the responsibility for solving homework compliance problems to the client. An overly responsible therapist suggests “Try this next time,” while a curious therapist probes by saying, “Tell me what you might try next time.” The following interaction illustrates a therapist curiously reviewing with a client her reasons for not completing the homework:

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Therapist: Okay Margo, let’s take a look at your homework. You were going to send your résumés to three job prospects we circled in the want ads last week. How did it go? Client: I’m really sorry. I forgot. It didn’t occur to me until just now when you mentioned it. Therapist: Oh, that’s too bad. I know you were excited about the homework when you left the session. Perhaps you and I could talk a few minutes about how this homework assignment slipped your mind. Would that be okay? Client: Sure. But I know why I forgot. Therapist: Yes. I hear that. And how do you think that happened? Client: What? I just forgot. You know me. I’d forget my head if it wasn’t attached to my shoulders. Therapist: This is interesting. I know you to be someone who forgets things from time to time, like all of us. But I also know you to be someone who remembers things that are important to you. For example, you never forget our appointments, even when I’ve had to move our meeting time around. And you never write down the appointment times. Can you see how this might puzzle me? How is it you remember you appointments with me but forget to do your homework? Client: Well, I don’t know. I just remember our appointments. Therapist: Yes, and can you understand why I’m puzzled? You’ve told me your family and friends are amazed that you’re so good at remembering things like birthdays and anniversaries, but you forgot to do your homework. What do you make of that? Client: I don’t know. You tell me. Therapist: Well, I don’t know either. But I’m not the expert about you, really. You’re the expert about you. What do you think? Client: Well, maybe sending out résumés just isn’t important to me. Therapist: I bet you’re right, and this is very important information. I’m sorry I missed this. How is it that this slipped by me? Client: I don’t know. Maybe you didn’t ask. Therapist: You know, you’re right. I didn’t check with you whether this homework assignment was important to you, and I apologize for that. I’m thinking I might drop the ball like this again. Would you be willing to help me with this? Client: Sure. What do you want me to do? Therapist: I’m curious about your ideas. Any ideas? Client: Well, I guess I could tell you. Therapist: Yes. Do you think that might help? Client: Yes, but that’s really hard for me. I don’t always know what’s important to me. Therapist: Yes. I know that’s true about you. Perhaps you have an idea of what you could do if we’re discussing a homework assignment and you’re not sure whether the homework assignment is important to you or not? Client: Maybe I could tell you that I’m not sure. Therapist: Yes. That would help me. Would that help you? Client: Yes. I think it would.

Be Collaborative It should be certain that the client—not just the therapist—has contributed to developing the homework assignment. There are clear advantages to the therapist and client working collaboratively to design an assignment. First, clients who have input into homework

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may perceive themselves as having greater control of the assignment itself; this may lessen anxiety and thereby increase the likelihood that the assignment will be tried as a result. Second, each time the therapist and client successfully work through misunderstandings and disagreements to set up homework, the therapeutic relationship is enhanced. Third, most times clients understand more fully than their therapists what is or is not a useful homework assignment and what difficulties may arise; the therapist who consults with clients about potential obstacles to homework increase the likelihood that the homework will be completed. Initially, the therapist assumes the responsibility for suggesting relevant homework assignments. As the therapy proceeds, however, the client is encouraged to share and then assume the responsibility for developing assignments. The therapist should start any discussion of potential assignments by asking the client, “ Perhaps you have an idea for a homework assignment that would help you with this problem?” At times, clients may suggest an assignment that seems not so relevant to the therapy’s focus or to their own treatment goals. Rather than dismissing the assignment out of hand, the therapist can explore the client’s rationale for the assignment, perhaps soliciting the advantages and disadvantages of this assignment over another one the therapist suggests. Sometimes after each person contributes an idea for an assignment, it may be necessary for the two to briefly negotiate a mutually agreeable assignment. Successful negotiations can strengthen the therapeutic alliance and thereby foster greater motivation to try this assignment and others in the future.

Reinforce All Pro-Homework Behavior When the client says “I thought about what I learned from the homework on my drive here today” or “ Perhaps I could try a little tougher exposure assignment this week,” the therapist should nod, smile, and praise them. Similarly, the therapist should avoid reinforcing homework noncompliance—refraining from saying “That’s okay,” “No problem,” or “No big deal” when such answers are not the truth, or “Better luck next time” when luck had nothing to do with it. When clients complete homework assignments, the therapist should congratulate them and chat for a few minutes to reinforce homework compliance, while taking care that the praise is appropriate to the effort and is not overblown or exaggerated. When the client fails to do homework, the therapist should respond in a neutral but curious manner and focus on identifying problems that may have contributed to homework noncompliance. If the homework was not completed (or attempted), set aside the entire session to review why the homework was not done—once again, in the manner of someone who is curious and puzzled by this turn of events. (“Did we make the homework too difficult? Were the homework instructions unclear? Did some unanticipated problem arise?”) When speaking to the client via telephone regarding homework, the therapist should focus only on the homework noncompliance and should not discuss other issues that may come up. Clients may find telephone contact with their therapist very rewarding and will use it to that end. If this appears to be happening, the therapist should get this issue out in the open to discuss at the next session (not during a telephone conversation). If the client has not completed the homework assignment, the therapist should either speak to the client about repeating the assignment and calling when it is completed; repeating the assignment with a change that the client and therapist could work out over the telephone; or end the conversation by recommending that the client discuss the assignment at the next scheduled session.

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Emphasize Homework Completion over Outcome Framing success in terms of compliance rather than outcome is particularly helpful for clients who may not receive immediate reinforcement for homework compliance in spite of their best efforts. For example, if a homework assignment for an unassertive woman is that she ask her husband to help her with the laundry this week, she should be praised if she asks, even if her husband says “No.” Prior to each homework assignment, the therapist should take a moment to define a successful homework assignment, saying something like, “There is no such thing as unsuccessful homework, because we learn something every time a homework assignment is tried. Remember, it is more important for you to try the homework as we’ve described it than it is for you to succeed at the homework task itself. If you have trouble completing the homework assignment, that’s okay. We can figure out what got in the way so that you can complete it next time.” Reinforce Successful Homework Approximations When the client attempts the homework and some part of it was successful, the therapist should focus on that part and praise the client’s efforts. (“Although we agreed that you would walk 5 minutes 3 times this week, you walked 5 minutes one day. Congratulations for walking 5 minutes that one day.”) Then, modifications to the homework assignment should be negotiated so that the client can do a bit more next time, and the homework should be reassigned. (“Now, let’s take a look at how we can help you meet your goal of 5 minutes each day. What do you say?”) However, if the client continues to fail to complete homework assignments, the therapist should consider breaking future assignments into smaller, doable pieces. In that way, the client can be reinforced positively for completing the entire homework assignment, even if it is smaller. The therapist should take care that the client does not interpret the effort to shape approximations to the desired homework to mean that incomplete homework will be accepted. The goal of rewarding small steps is to have the client always complete homework consistently and as agreed upon. When the therapist notices that the client tries homework assignments but still fails to complete them, the therapist should discuss this issue directly. Summary This article described several guidelines for therapists to enhance homework compliance in daily clinical practice, including his ensuring that the homework assignments are meaningful, doable, and have a clear rationale tied to the client’s treatment goals. Other guidelines focused on features of the therapist’s manner that influence homework compliance, such as being curious, collaborative, and emphasizing homework completion over outcome. While the therapist may want to emphasize certain guidelines with certain clients, I recommend implementing all guidelines with every new client in order to get homework off to a good start. The therapist may discover, however, that when setting up and reviewing homework assignments, even after careful attention to the assignment’s structure and the therapist’s own manner, certain clients consistently fail to complete the homework they have agreed to do. In these instances, client factors come to the fore, and the therapist must manage homework noncompliance as they might any other client behavior that interferes with progress toward the client’s treatment goals. To effectively manage homework noncompliance, the therapist needs to understand the function of noncompliance for a particular client at a particular point in therapy. A comprehensive case formulation is particularly

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helpful in managing noncompliance of all sorts, including clients’ repeated failures to complete homework (Persons, 1989; Shelton & Levy, 1981; Tompkins, 1999). In conclusion, no matter how carefully therapists follow the guidelines presented in this article, clients will not do homework unless their therapists take an active interest in it. It is hoped that this article will inspire greater therapist interest in homework, and its important role in the therapeutic process. Select References/Recommended Readings Addis, M.E., & Jacobson, N.S. (1996). Reasons for depression and the process and outcome of cognitive-behavioral psychotherapies. Journal of Consulting and Clinical Psychology, 64, 1417–1424. 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. Beck, A.T., Rush, J.A., Shaw, B.F., & Emery, G. (1979). Cognitive therapy for depression. New York: Guilford. Beck, J.S. (1995). Cognitive therapy: Basics and beyond. New York: Guilford. Cox, D.J., Tisdelle, D.A., & Culbert, J.P. (1988). Increasing adherence to behavioral homework assignments. Journal of Behavioral Medicine, 11, 519–522. 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. Fennell, M.J.V., & Teasdale, J.D. (1987). Cognitive therapy for depression: Individual differences and the process of change. Cognitive Therapy and Research, 11, 253–271. Goldfried, M.R., & Davison, G.C. (1976). Clinical behavior therapy. New York: Holt, Rinehart, and Winston. Kazantzis, N., & Deane, F.P. (1999). Psychologists’ use of homework assignments in clinical practice. Professional Psychology: Research and Practice, 30, 581–585. Levy, R.L., & Shelton, J.L. (1990). Tasks in brief therapy. In R.A. Wells & V.J. Giannetti (Eds.), Handbook of the brief psychotherapies (pp. 145–163). New York: Plenum. Norcross, J.C., Alford, B.A., & DeMichele, J.T. (1992). The future of psychotherapy: Delphi data and concluding observations. Psychotherapy, 29, 150–158. Organista, K.C. (1995). Cognitive-behavioral treatment of depression and panic disorder in a Latina client: Culturally sensitive case formulation. In Session: Psychotherapy in Practice, 1, 53– 64. Padesky, C.A. (1994). Schema change processes in cognitive therapy. Clinical Psychology and Psychotherapy, 1, 267–278. Persons, J.B. (1989). Cognitive therapy in practice: A case formulation approach. New York: Norton. Persons, J.B., Davidson, J., & Tompkins, M.A. (2001). Essential components of cognitive-behavior therapy for depression. Washington, DC: American Psychological Association. Shelton, J.L., & Ackerman, J.M. (1974). Homework in counseling and psychotherapy: Examples of systematic assignments for therapeutic use by mental health professionals. Springfield, IL: Charles C. Thomas. Shelton, J.L., & Levy, R.L. (1981). Behavioral assignments and treatment compliance: A handbook of clinical strategies. Champaign, IL: Research Press. Tompkins, M.A. (1999). Using a case formulation to manage treatment nonresponse. Journal of Cognitive Psychotherapy, 13, 317–330.