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Running head: PROBLEMS WITH HOMEWORK COMPLIANCE
Problems with homework compliance in CBT: Rare
exception or rather frequent?
Sylvia Helbig1 & Lydia Fehm
Clinical Psychology and Psychotherapy
Dresden University of Technology
1Author for Correspondence:
Dipl.-Psych. Sylvia Helbig
Clinical Psychology and Psychotherapy
TU Dresden
Chemnitzer Str. 46
01187 Dresden
Germany
Phone: +49 (0) 351/463-36958
Fax: +49 (0) 351/463-36984
Mail to: [email protected]
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Abstract
Today, homework assignments are an essential part of
cognitive-behavioural therapy, being included in the
majority of therapy manuals and frequently used in
therapeutic practice. Despite of this, problems with
homework completion seem to be a frequent phenomenon.
Yet, there is little known about these problems and
possible influences on homework compliance. Aim of the
present study was to enhance findings about frequency
and procedures of homework use and occurring problems.
77 cognitive-behavioural therapists participated in the
study assessing general questions regarding homework
assignments and problems with it. Additionally,
therapists were asked to recall two individual patients
and report about a specific homework assignment and
possible problems. Results suggest that problems quite
usually occur when homework is used in cognitive-
behavioural therapy. General motivation for therapy and
homework and a late stage of therapy were positively
linked to homework compliance. For assigning
procedures, a written note or working materials were
positively associated with homework completion.
Regression analyses showed patient variables as most
decisive for homework compliance. Implications for
effective homework use in clinical practice are
discussed.
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KEY WORDS: homework assignments, compliance, cognitive-
behavioural therapy
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Introduction
During the past decade, homework and its use in
psychotherapy has become an important element within
therapy research. A few surveys were conducted (e.g.
Borgart & Kemmler, 1991; Kemmler, Borgart & Gärke,
1992; Kazantzis & Deane, 1999; Fehm & Fehm-Wolfsdorf,
2001) among therapists with different therapeutic
orientations regarding attitudes towards homework and
its usage in therapeutic practice. Their results
indicated homework assignments as an essential part of
psychotherapy in general and cognitive-behavioural
therapy in special. Most therapists appraised homework
as important for therapy and used it for a majority of
patients with a variety of problems. Despite of these
findings, therapists reported a lack of information
about homework in therapist training programs and
furthermore, problems emerging from homework use. In
Borgart and Kemmler’s study (1991), 60% of behavioural
therapists reported homework assignments being
frequently modified by the patient. Admittedly, when
homework in general is evaluated, it is rated to be a
rather uncomplicated element of therapy (Fehm & Fehm-
Wolfsdorf, 2001).
This points out to homework compliance as a potentially
underestimated problem in cognitive-behavioural
therapy. Focussing on problems with homework in further
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studies is especially warranted given that compliance
with homework is positively linked to therapy outcome
(see the meta-analysis by Kazantzis, Deane & Ronan,
2000).
Consequently, the establishment and improvement of
homework compliance should be a major aim in the
therapeutic process. A closer look on conditions and
reasons for inadequate homework completion appears
necessary for understanding problems with homework and
inferring methods to enhance homework compliance.
Surprisingly, there are only few studies focusing on
potential factors linked to homework compliance. Based
on related findings, Detweiler and Whisman (1999)
proposed a model of factors linked to homework
compliance, including characteristics of the task, the
patient and the therapist as main components. Prior
research findings are introduced according to this
model.
Among task characteristics, only task difficulty has
already been examined. Conoley, Padula, Peyton and
Daniels (1994) showed that less difficult homework
tasks were more likely to be carried out than difficult
ones.
With regard to patient characteristics, especially the
role of symptom severity was explored. Unfortunately,
findings were mixed. While Edelman & Chambless (1993)
6
found patients with more severe symptoms being less
likely to comply with homework assignments, other
studies (Edelman & Chambless, 1995, Leung & Heimberg,
1996, Burns & Spangler, 2000) failed to prove such an
association. A further study (Bryant, Simons & Thase,
1999) likewise found no effect of pre-treatment symptom
severity but patients with more previous depressive
episodes tended to comply less with homework
assignments. Other patient characteristics examined
were demographic variables as age and years of
education (Bryant et al., 1999) and patient’s
motivation for treatment (Sutton & Dixon, 1986). For
these variables, only motivation was related to
homework compliance.
For therapist characteristics, it seems necessary to
modify the suggested model by discriminating
therapist’s style and therapist’s behaviour during
homework assignment. Concerning therapeutic style,
Burns and Spangler (2000) found no relation between
empathic behaviour in patients’ ratings and compliance,
while in a study of Edelman and Chambless (1993)
patients were more likely to comply when they perceived
their therapist as highly self-confident.
Findings concerning assigning procedures on the other
hand supply clear evidence for associations between
homework compliance and recommended assigning
7
procedures. Cox, Tisdelle and Culbert (1988), for
instance, compared oral and written homework
assignments in an experimental design Their results
showed that patients rated themselves as more compliant
when they had received a written homework prescription.
Bryant et al. (1999) could demonstrate that reviewing
homework predicted compliance with the next assignment.
However, therapist’s behaviour during assignment (e.g.
patient’s involvement, providing a rationale) was
unrelated to homework compliance when rated by the
patient (Startup & Edmonds, 1994). Albeit this
evidence, it has to be stated that systematic
assignment procedures seem to be only partially used in
therapeutic practice (Kazantzis & Deane, 1999).
Ambiguous results described above may stem from the
different approaches to measure patient’s compliance.
Additionally, interrelations between variables mostly
remain unconsidered as well as other sources of
variance, e.g. kind of task or previous experiences. As
a further complication samples are rather small so that
small and middle effects may remain undetected (see
Kazantzis, 2000).
A major aim of the present study was to extend
knowledge about appearing problems and their
frequencies during assignment and completion of
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homework. Variables linked to homework completion were
to be identified and used to predict compliance.
Method
Assessment
The questionnaire used in the study comprised three
sections. The first assessed therapists’
sociodemographic data as age, sex, therapeutic
orientation and experience in hours of therapy as well
as the current work setting. The second section
included questions addressing the use of homework
assignments in general (e.g. frequency of homework use,
time spent with assigning and checking homework,
methods used to enhance homework compliance and
frequency of problems with homework compliance).
In a last section the therapists were asked to remember
the last two patients, they had reviewed an assigned
task with. For each of the patients information about
gender, age and all diagnoses were assessed as well as
ratings of his or her motivation to comply with
treatment in general and with homework assignments
specifically. For all patients the given task had to be
described in own words and in addition, had to be
classified in categories of homework types (e.g.
bibliotherapy, reflection, behavioural exercises).
Therapists were demanded to evaluate task difficulty
and frequency as well as the overall time assumingly
9
needed to fulfil the task. Categories were presented to
answer these questions (e.g. for time needed to fulfil
the task: "less than 10 minutes", “10 to 30 minutes”,
“30-60 minutes”, “60 to 90 minutes”, “90 to 180
minutes” and “ more than 180 minutes”). Assessment of
assigning procedures included questions regarding the
time the homework was fixed (e.g. “before the session”
or “during the session”), who determined the assignment
(“therapist”, “patient” or “both”), the specificity of
homework recommendation (time, location, circumstances)
and whether materials or written notes were used. As
before, answering categories were provided for the
majority of items, data were mostly categorical or
ordinal.
The last part of the questionnaire investigated
problems during the assignment and the compliance,
which was operationalised as the degree of homework
completion in extent, difficulty and content of the
task (as proposed by Primakoff, Epstein and Covi,
1986). Completed homework was to be rated for these
aspects with help of the categories “as assigned”,
“slightly reduced” and “significantly reduced”. For
analysis, compliance was transferred into a four-point
rating with "0" for a missing homework, "1" for
homework that had been significantly reduced in at
least one aspect and "2" for slightly reduced homework.
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Full compliance ("3") allowed at maximum one slight
reduction.
Procedure
Questionnaires, cover letters and prepaid return
envelopes were sent to 68 registered cognitive-
behavioural psychotherapists working in private
practice of which 29 returned.
In addition, questionnaires were distributed among
clinical psychologists in four therapy-training
courses. During these courses participants work in a
variety of settings, e.g. inpatient settings,
counselling etc. and additionally attend regular
lessons on cognitive-behavioural therapy. Treatment of
outpatients in an individual setting is a main part of
the training’s second half. Questionnaires were
distributed among 60 participants with a return rate of
48.3% (n = 29). To enlarge the sample, questionnaires
were handed out at a behavioural therapy convention in
Dresden. Another 15 psychotherapists and six
psychologists in training completed the questionnaire
yielding a total sample of 79. Two questionnaires had
to be excluded from analysis because the therapists did
not work in an outpatient setting or individual
therapy.
Participants
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Therapists: The sample consisted of 77 therapists (55
female; 71.4%). Forty-two of them worked in private
practice and 35 took part in a training program for
cognitive-behavioural therapy at four different
institutions in Germany (Dresden, Bochum, Lindow,
Frankfurt). All participants worked at least sometimes
in an outpatient setting with individual patients.
Nearly all therapists reported cognitive-behavioural
therapy as main therapeutic orientation, only ten
therapists combined cognitive-behavioural interventions
with other therapeutic approaches (e.g. systemic
therapy). As anticipated, the two sample groups
differed in age (t(72, 74) = 6.88, p = .021) with the
psychotherapists in private practice being older but
not in gender (Χ2[1, 77] = 0.56, p = .608; see table
1). Clinical experience varied from less than 100 hours
of therapy to more than 7000 hours. Therapists in
training were significantly less experienced than their
colleagues in private practice (Χ2[7, 77] = 52.92, p <
.001). Sociodemographic information is summarised in
table 1.
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Please insert table 1 about here
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Indirect patient sample: Therapists provided
information about 149 outpatients with a gender
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distribution of 69.1% female (n = 103) and 30.9% male.
Mean age was 37.5 years (SD = 11.63).
As most common primary diagnosis, anxiety disorders
were reported with 32.9% (n = 49), followed by
affective disorders with 26.8% (n = 40). Other primary
diagnoses were personality disorders (10.7%, n = 16),
adjustment disorders (8.7%, n = 13) and somatoform
disorders (8.1%, n = 12). Less common were eating
disorders (n = 8) and substance related disorders (n =
4). A last category (n = 7) contained diagnoses with a
frequency below n = 2 (e.g. insomnia, schizophrenia).
74 (49.7%) patients got at least one secondary
diagnosis; up to three more diagnoses were assigned.
Most frequent additional diagnoses were personality
disorders (19.5% of all patients), followed by mood
disorders with 17.4% and anxiety disorders with 16.0%.
Therapists reported 19.7% of patients to be in an
initial stage of their therapy, 68.0% in a middle stage
and 12.2% in relapse prevention.
Results
Description of homework assignments
Most therapists (72.7%, n = 56) reported the use of
homework in at least 75% of all individual therapies.
None of the therapists reported to never assign
homework. Within a therapy, homework was used by 48.1%
of therapists in three fourth of sessions or more
13
often, while another 36.4% used it in about half of the
sessions. For assigning homework, most therapists
(89.5%, n = 68) spent 1 to 10 minutes of session time,
while reviewing an assignment lasted significantly
longer (Χ2[9, 77] = 60.6, p < .001). 85.7% (n = 66) of
therapists invested 5-15 minutes for that. Homework was
controlled at least “in most cases” (57.1%) or even
“always” (42.9%).
Tasks described by the therapists were classified as
either “cognitive task“ or “behavioural task“ to check
the influence of special types of homework on problems
and homework completion.
More than half of the assignments (62.4%) were
categorised as “cognitive task”, including
bibliotherapy, reflection, questionnaires and
protocols. Behavioural tasks were exposure or
confrontation tasks, planning/carrying out positive
activities and checking assumptions. Table 2 presents
task characteristics and differences between cognitive
and behavioural tasks.
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Please insert table 2 about here
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As shown above, cognitive and behavioural assignments
did not differ in difficulty or time required but
cognitive tasks had to be carried out significantly
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more often during a week than behavioural tasks (Z
[147] = 1.65, p = .009). Therapists rated their
homework assignments in 44.3% as “difficult” or even
“very difficult”. Another 38.9% were regarded as medium
difficulty. There were no “very easy” tasks.
Assigning procedures
Assigning procedures were all in all heterogeneous and
differed depending on the type of task. Over all, 64.2%
of homework was derived from session contents, the
other 35.8% were fixed before session by the therapist.
In 52.3% of cases, therapists themselves decided about
the task. Regarding to difference between the homework
types, patients were more often involved in assigning
behavioural than cognitive tasks (71.4% vs. 33.3%,
Χ2[1, 149] = 20.34, p < .001). Therapists described
behavioural assignments clearer and more in detail of
when and how to do the homework (Χ2[2, 149] = 10.36, p
= .006). Location, time and circumstances of homework
completion were totally left to the patient in 44.3% of
all assignments (47.3% of cognitive tasks; 39.3% of
behavioural tasks). Written instructions or working
materials were used in 65.6% of cognitive homework but
only in 30.4% of behavioural assignments (Χ2[1, 149] =
17.49, p < .001). All in all, therapists provided in
52.3% of assignments a written homework prescription.
Problems with homework
15
Problems emerging during the assignment of homework
(acceptance problems) and reductions in task completion
(compliance) occurred regularly. Therapists reported
difficulties with homework (acceptance and/or
completion) for 74.5% (n = 111) of all patients.
Regarding homework acceptance, problems were
perceived in 53.0% (n = 79) of cases. Most problems
were described as “patient doubts his/her ability to
complete the task” (57.0%) and “patient complains about
the difficulty of the task” (19.0%). Other problems
mentioned were complaints about the extent of the task
(5.1%), unwillingness (6.3%) or – in two cases each -
fear of failure and organisational problems.
In 64.6% of cases therapists responded to those
problems by explaining goals and background of the
assigned task. Only two therapists actually reduced the
extent of a given task.
Regardless of acceptance problems, therapists were
quite often unsatisfied with the patient’s homework
completion. Although there were only few patients (n =
16; 11.0%) who completely missed to fulfil an
assignment, therapists rated homework completion just
in 38.9% of cases as “totally completed as assigned”,
whereas most completions were classified as slightly
reduced in at least one aspect. Most frequently (48% of
all cases), patients reduced the extent of an assigned
16
task. For further analyses a compliance index was
calculated. It allowed one slight reduction in homework
completion for a patient rated as fully compliant.
Regarding this more liberal measure, 63.0% of all
patients were rated as compliant. In 13.0% homework
completion was regarded as slightly reduced, another
13.0% were significantly reduced.
Therapists reported several reasons that patients used
as an explanation for homework reduction, e.g. “task
was to difficult” (35.9%, n = 18), “no occasion for
homework completion” (17.6%, n = 15) and “task was
avoided because of fear” (20.3%, n = 11). Only in three
cases, homework completion was reduced because of a
general unwillingness to do it (5.2%).
Interestingly, the difficulty of a task was most
frequently indicated as reason for a noncompliant
homework solution, while therapists more often
criticized reduction in the extent of homework rather
than its difficulty.
Factors related to reduced homework completion
In order to examine possible predictors for homework
compliance, all variables were correlated to the
compliance index.
Variables were classified as characteristics of task,
therapist or patient according to the Detweiler and
Whisman-model (1999) introduced above. Additionally,
17
assigning procedures were inspected. Table 3 provides
all correlations.
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Please insert table 3 about here
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Surprisingly, no significant relationships between
characteristics of the task and homework compliance
could be detected. Neither difficulty nor time
necessary for task completion or the type of task
(cognitive vs. behavioural) was related to the extent
of homework completion. There was an association
between time span for homework completion and
compliance, indicating that compliance decreases if
more than two weeks time passes between assignment and
review of homework.
Patient characteristics seemed to be more closely
associated with compliance. As to be expected,
correlations between compliance and therapist’s rating
of motivation for therapy and homework were found. Male
patients tended to comply less with homework
assignments. Additionally, an earlier phase of therapy
was significantly associated with lower compliance. All
diagnostic groups as well as the number of diagnoses
for one patient were unrelated to the extent of
homework completion.
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For therapist variables, compliance was lower for male
therapists. Other characteristics as age or therapeutic
experience did not influence the degree of homework
completion.
Within therapist behaviour during homework assignment,
providing written instructions or working materials was
the only variable associated with higher degrees of
compliance. Based on recommendations of task assignment
in literature, an index for cooperative therapist
behaviour was formed. This index included patient’s
participation on task assignment, the direct connection
to session’s contents, a concrete and specific
instruction and a written instruction or working
materials for the patient. Patients were more likely to
comply, if these recommendations were considered (ρ =
.209, N = 142, p = .012). Furthermore, patients reduced
homework more often when there had already been
acceptance problems during the assignment.
It should be noted that results remain about the same
when compliance is operationalized as summed score of
all three ratings assessing extent, content and
difficulty of task completion.
Prediction of homework compliance
In order to determine the relative influence of the
found associations to homework compliance, a polytomous
ordinal regression analysis (PLUM-procedure) with
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compliance as the dependent variable was computed. All
variables significantly linked to homework compliance
(see table 3) were entered simultaneously as
predictors. The analysis achieved an adjusted R2 of
55.4%. Being a female therapist, a later stage of
therapy, patient’s general motivation for homework and
providing a note with a prescription of the task
significantly predicted homework compliance. Table 4
depicts all results of the analysis.
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please insert table 4 about here
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Discussion
The present study confirmed homework as an important
element in cognitive-behavioural therapy and showed
that problems with homework are rather frequent than
the exception. Already during assignment, problems
emerge in more than 50% of all cases. Most frequent
problem is thereby patient’s doubts about his or her
ability to complete the task. Interestingly, therapists
react to those worries mostly by explaining goals and
background of a task but rarely modify the task itself
to match it with the patient’s abilities. Based on
previous results, that building homework on patient’s
strength increases is positively related to homework
compliance (Conoley et al., 1994), this reaction has to
20
be regarded as problematic. Furthermore, during
assignment therapists do not follow all recommendations
given in literature.
Compliance itself is also found being often reduced,
although therapists note only slight reductions in most
cases. Nevertheless, compared to former studies that
asked for an overall evaluation (e.g. Kemmler et al.,
1992; Fehm & Fehm-Wolfsdorf, 2001) problem frequencies
seems to enlarge when examined on the individual level.
Task characteristics seem to exert a low influence
on patient’s completion of a task. Results of Conoley
et al. (1994), pointing to task difficulty as predictor
for homework compliance could not be replicated. The
differing results may be explained by methodical
issues, as in the present study only therapist ratings
for task difficulties were available.
Findings on patient characteristics fit well in prior
research. As Sutton and Dixon (1986) showed before,
patient’s motivation is strongly linked to homework
compliance. Still it remains unclear, if motivation is
a real predictor for compliance or homework compliance
is regarded as a sign for high motivation, especially
when one and the same person rates both variables.
Interestingly, there are no associations of compliance
to any primary diagnosis or the number of diagnoses.
Influences of special disorders or syndromes are rarely
21
discussed since most studies examining homework
compliance focus on patients with one specific
disorder. Only Edelman and Chambless (1995) reported a
significant positive correlation between the score for
dependent personality traits and compliance.
Comparisons between diagnostic groups have not been
published to date. On the other hand, it seems
important to know, if patients presenting specific
symptoms are more likely to neglect homework and
therefore need special attention. Present results
indicate homework compliance as independent from
diagnostic status but it has to be noted that some
diagnostic groups were rather small and possible
effects could remain undetected.
In accordance to Cox et al. (1988), results suggest
that providing the patient with a written note or
working material about a homework assignment enhances
compliance. Other recommendations as patient’s
involvement in assigning a homework cannot be proved as
influential for homework compliance in this study. On
the other hand, data shows that problems occurring
during the assignment may lead to later compliance
problems and should therefore be thoroughly handled.
Among all variables examined as possible predictors of
compliance, the stage of therapy and the use of a
22
written homework prescription show to be the most
influential factors.
Findings of this study are limited for some reasons.
First, participation on the study was voluntary and it
cannot be ruled out that only therapists with a
positive attitude towards homework took part in the
study. As already mentioned only therapists’ view is
considered. It has been shown, that therapists’ and
patients’ ratings of homework compliance are
significantly matched (Burns & Nolen-Hoeksema, 1991),
but it remains unclear, if patients’ ratings, e.g.
concerning task difficulty, would be the same.
Furthermore, data were collected observationally for
only a single task that may not be representative.
Although therapists were instructed to describe the
last two patients they had a homework arrangement with,
distortions are possible since it is left unclear, how
typical a task was in terms of assigning procedures and
homework completion through the patient. Relations
between patient characteristics and compliance should
be interpreted cautiously.
Despite of these critical issues some recommendations
concerning homework use in clinical practice can be
inferred. Especially at first stages of a therapy,
therapists assign homework tasks that are manageable
and accord to the patient’s abilities. Objections
23
raised against a proposed homework have to be seriously
dealt with. Moreover, every homework assignment should
include working materials or at least a note describing
the task.
Further research on factors related to homework
compliance should extend the focus on both therapist’s
and patient’s view. A last proposal relates to the
finding that existing recommendations for the effective
use of homework in psychotherapy (e.g. Kazantzis &
Deane, 1999; Broder, 2000; Tompkins, 2002) are only
partially implemented by therapists. It should be
further examined, if therapists are actually not
familiar with these recommendations or if other
obstacles interfere with transferring the proposals in
everyday practice.
24
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28
Table 1: Demographic information and therapeutic
experience
Psycho-therapists (n = 42)
Therapists in training (n = 35)
Total Sample (N = 77)
Gender female 32 24 56 (%) 76.2 68.6 72.7 Age MW (SD) 44.2 (8.59) 32.1 (6.04) 38.6 (9.63) Range 31-62 25-55 25-62 Therapeutic < 100h - 6 6 experience 100-500h - 9 9 (in hours) 500-1000h 2 10 12 1000-2000h 1 6 7 2000-4000h 4 - 4 4000-7000h 15 2 17 > 7000h 18 1 19 Regular outpatient 42 9 51 working inpatient - 15 15 setting university - 4 4 other - 7 7 Percentage of MW (SD) 94.5 (8.59) 66.8 (31.13) 83.1 (25.45)Psychotherapy among every day work
Range 50-100 5-100 5-100
29
Table 2: Characteristics of assigned tasks (all in
percent)
cognitive tasks
(n = 93)
behavioural tasks
(n = 56)
differences
once 29.3 25.5 Z = 1.65; 2-3 times a week
10.9 41.8 p = .009
4-5 times a week
4.3 5.5
Frequency of completion
daily 55.4 27.3 < 10 minutes 17.2 14.5 Z = 0.83; 10-30 minutes 38.7 32.7 p = .489 30-60 minutes 18.3 12.7 60-90 minutes 14.0 21.8 90-180 minutes
5.4 3.6
Total time spent with the task
> 180 minutes 6.5 14.5 difficulty very easy 0 0 Z = 0.54; easy 17.2 16.1 p = .932 medium 41.9 33.9 difficult 28.0 32.1 very
difficult 12.9 17.9
30
Table 3: Variables linked to homework compliance
Variable group Variable Spearman ρ p Task time since assignment -.21* .013 characteristics behavioural task .05 .537 task difficulty -.14 .084 task frequency .10 .144 time spent on the task .00 .987 Patient male -.17* .041 characteristics age -.15 .069 stage of therapy .31** < .001 motivation for therapy .36** < .001 motivation for homework .55** < .001 number of diagnoses .05 .524 Therapist male -.25** .003 characteristics age -.07 .433 experience .00 .970 Assigning procedures
homework was derived from session contents
-.06 .470
homework was assigned by therapist and patient
.12 .165
homework was specified in time and location
.14 .089
note or working material was used
.25** .002
number of problems during assignment
-.35** < .001
31
Table 4: Results of multiple ordinal regression
analysis (PLUM) predicting homework compliance
Variable group predictor exp. B1 W2 p Task characteristics
time since assignment
-3.40 3.81 .051
Patient female .32 .51 .477 characteristics early stage of
therapy -3.06 8.22 .004
general therapy motivation
-.46 .59 .440
low homework motivation
-3.87 18.52 <.001
Therapist characteristics
female .53 1.42 .233
Assigning procedures
no written prescription
-1.15 5.96 .015
no problems during assignment
.69 2.32 .128
1 parameter estimate
2 Wald test: estimated coefficient divided by its standard error
