The Process of Recommending Homework in Psychotherapy: A Review of Therapist Delivery Methods, Client Acceptability, and Factors That Affect Compliance.

Although the link between homework use and positive psychotherapy outcomes has been established, relatively little is known about the therapeutic processes, or factors, that promote homework compliance. Homework compliance may be viewed as an indicator of client commitment and involvement in psychotherapy. This article presents the results of a systematic review of research, including 16 empirical studies, related to the homework recommendation process. Findings relate to the frequency and type of homework that therapists deliver, factors that promote client acceptability of homework recommendations, and factors that affect compliance. On the basis of these findings, the authors propose a theoretically and empirically based, 6-phase conceptual model of the homework recommendation process. They also propose specific strategies for recommending homework to clients and directions for future research. Therapist recommendations to clients to perform out-of-session actions, commonly called homework, are related to positive psychotherapy outcomes. Results of a recent meta-analysis of 27 studies of cognitive and behavioral therapies, representing 375 clients, indicate that this relationship is strong (r = .36; 95% confidence interval [CI] = 0.23–0.48; Kazantzis, Deane, & Ronan, 2000). In this study, homework compliance was also significantly correlated with positive outcomes (r = .22; 95% CI = 0.22–0.22; N = 1,327). Furthermore, studies indicate that the homework–outcome relationship is linear, with clients who do the most homework improving more than clients who do little or no homework (Burns & Auerbach, 1992; Burns & Spangler, 2000; Neimeyer & Feixas, 1990; Persons, Burns, & Perloff, 1988; Zettle & Hayes, 1987). Studies also indicate that cognitive–behavioral therapy (CBT) with homework, compared with CBT without homework, is more effective (Bryant, Simons, & Thase, 1999; Neimeyer & Feixas, 1990). Finally, clients who comply with homework recommendations in cognitive therapy have been shown to benefit more than clients who do not (Bryant et al., 1999). Despite the strong, positive relationship between homework and psychotherapy outcomes, little empirically driven attention has been directed toward studying strategies to use in recommending homework and in gaining compliance from clients to complete homework. Although several reviews related to homework and psychotherapy outcomes have been published (Detweiler & Whisman, 1999; Glaser, Kazantzis, Deane, & Oades, 2000; Kazantzis, 2000; KaPublished in Psychotherapy: Theory, Research, Practice, Training 41:1 (Spring 2004), pp. 38-55; doi 10.1037/00333204.41.1.38 Copyright © 2004 Educational Publishing Foundation; published by the American Psychological Association. Used by permission. “This article may not exactly replicate the final version published in the APA journal. It is not the copy of record.” The Process of Recommending Homework in Psychotherapy: A Review of Therapist Delivery Methods, Client Acceptability, and Factors That Affect Compliance Michael J. Scheel, William E. Hanson, and Tanya I. Razzhavaikina Department of Educational Psychology, University of Nebraska–Lincoln Corresponding author — Michael J. Scheel, Department of Educational Psychology, 38 Teachers College Hall, University of Nebraska, Lincoln, NE 68588-0345; email mscheel2@unl.edu