Definitions of Homework, Types of Homework, and Ratings

of the Importance of Homework Among Psychologists

With Cognitive Behavior Therapy and Psychoanalytic
Theoretical Orientations
m

Nikolaos Kazantzis
La Trobe University
m

Frank M. Dattilio
Harvard Medical School

A random sample of 827 psychologists were surveyed to assess their

definitions of homework, use of homework tasks, and perceived
importance of homework. Theoretical orientation distinguished
practitioners’ responses. Cognitive-behavioral therapists defined
homework as being closer to empirically supported therapy, whereas
psychodynamic therapists rated homework as less characteristic of a
process that embraces client responsibility and adaptive skills.
Cognitive-behavior therapists did not limit their choices to activity-
based tasks, and psychodynamic therapists reported using behavioral
tasks ‘‘sometimes.’’ Monitoring dreams and conscious thought were
also used among the entire sample surveyed. Psychodynamic
therapists rated homework as ‘‘somewhat’’ or ‘‘moderately’’
important, whereas cognitive-behavior therapists more often rated
homework as ‘‘very important.’’ Data suggest some homework may
be common to different psychotherapeutic approaches. Findings are
discussed in the context of recent theoretical work on homework in
psychotherapy and recommendations for future research. & 2010
Wiley Periodicals, Inc. J Clin Psychol: 66:758–773, 2010.

Keywords: homework assignments; psychotherapy; practitioner survey

The authors thank Louis Castonguay, Jerry Gold, Laura Mufson, Robert Neimeyer, and George Stricker
for comments on a previous version of this manuscript.
The authors thank Georgios K. Lampropoulos and Frank P. Deane for their contributions to data
collection and agreement to the use of data for presentation purposes.
Correspondence concerning this article should be addressed to: Nikolaos Kazantzis, School of
Psychological Science, La Trobe University, Victoria 3086, Australia; e-mail: [email protected]

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 66(7), 758--773 (2010) & 2010 Wiley Periodicals, Inc.
Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.20699
 Definitions, Types, and Importance of Homework 759

Between-session ‘‘homework’’ has enjoyed a renaissance with the advent of short-

term treatments, particularly the behavioral and cognitive psychotherapies (Beck,
Rush, Shaw, & Emery, 1979; Kazantzis, MacEwan, & Dattilio, 2005; Marks et al.,
1988; Shelton & Ackerman, 1974).1 Systemic approaches have also considered
homework integral to therapy since their inception (Dattilio, 2002; L’Abate,
L’Abate, & Maino, 2005). Early directive and psychoanalytic therapies incorporated
the concept of extending therapeutic work with between session tasks, though they
did not necessarily feature as a routine part of clinical practice (Dunlap, 1932;
Herzberg, 1941; Thorne, 1948). A less directed process for using such activities has
also been adopted within client-centered, constructivist, emotion-focused experi-
ential, family, interpersonal, and psychodynamic approaches (see review in Nelson,
Castonguay, & Barwick, 2007). This literature has clarified important differences in
the process for integrating homework tasks between psychotherapies. However, little
data exist on the specific types of homework tasks that practitioners actually discuss
with patients.
Existing data support the use of homework assignments as a frequent strategy in
clinical practice. A survey by Kazantzis, Lampropoulos, and Deane (2005) found
that 68% of psychologists reported using homework assignments ‘‘often’’ or ‘‘almost
always.’’ Compared with their psychoanalytic colleagues, practitioners espousing a
cognitive-behavioral orientation maintained more positive beliefs about the
effectiveness of homework on therapy outcomes. Similar differences in theoretical
orientation emerged regarding the potential for homework to have a negative impact
on in-session processes. Other studies have found similar differences in attitudes by
theoretical orientation (Fehm & Kazantzis, 2004). These surveys of practitioners of
psychotherapy are inconsistent with the view espoused by some researchers that
‘‘homework’’ is something that differentiates behavior and cognitive therapies from
psychoanalytic therapies (Blagys & Hilsenroth, 2002; Goisman, 1985). Indeed, a
special issue of the Journal of Psychotherapy Integration (volume 16, issue 2)
presented a series of case reports by expert psychotherapists on the way different
therapeutic models emphasize between-session therapeutic activities in promoting
lasting patient change (see also Kazantzis & L’Abate, 2007). There is now a need to
better understand how homework is conceptualized, or defined, by practitioners
working in the field.
Interventions extracted from ‘‘empirically supported’’ therapies may prove
beneficial to patients, but they are ideally utilized within a theory and system
of psychotherapy. Theoretical models include assumptions about patients’ problems
that are evaluated through the use of techniques and interventions. Patients
then describe and demonstrate the benefits of interventions on alleviating
symptoms, interpersonal strains, and difficulties in other important areas of
functioning. Some therapists may extract interventions from empirically supported
treatment manuals or select predetermined schedules of assignments based on
published compendiums (see Schulthesis, 1998, and Wiley Series). However,
conceptions of what constitutes homework will likely depend upon principles of
any given therapeutic model.
Behavioral and cognitive therapy approaches often define or operationalize
homework as a discrete ‘‘task,’’ such as assertiveness behavior designed to improve
interpersonal interaction (Beck, 1995; Kazantzis, 2005). Insight-orientated therapies

1
Readers are cautioned about using the term ‘‘homework’’ in clinical practice because of the many
associations with this word (see discussions in Kazantzis, MacEwan, & Dattilio, 2005; Nelson et al., 2007).

Journal of Clinical Psychology DOI: 10.1002/jclp

760 Journal of Clinical Psychology, July 2010

often include reflecting on an insight derived from a previous session without any
specific recording or behavioral activity as part of their definition for homework
(Brodley, 2006; Greenberg, Watson, & Goldman, 1988; Stricker, 2007). Thus, the
same homework may be incorporated into different therapies to achieve different
outcomes. A practitioner of Beck’s cognitive therapy (Beck et al., 1979) may use an
empty chair technique, for example, to evaluate ‘‘intermediate’’ level assumptions
regarding a particular interpersonal interaction, despite the fact that the technique
was never designed with such a model in mind. Similarly, a therapist practicing
behavioral activation therapy may work with a patient to schedule problem-solving
activities, distress tolerance activities, and/or flow activities. Therefore, it is plausible
that a therapist’s theoretical approach may only dictate a limited portion of the
homework assignments they use. However, no prior study has sought to examine
how practitioners define homework or what types of homework activities they
actually use (Lambert, Harmon, & Slade, 2007).
The existing data regarding homework assignments have focused on its relation-
ship with treatment outcome within the cognitive-behavioral therapies (see review in
Kazantzis, Deane, & Ronan, 2000). Only a small proportion of the existing research
has assessed the theoretically meaningful aspects of the mechanism by which
homework assignments produce effects, such as acquisition of cognitive restructur-
ing skills (Burns & Spangler, 2000; Neimeyer & Feixas, 1990; Neimeyer, Kazantzis,
Kassler, Baker, & Fletcher, 2008; Schmidt & Wollaway-Bickel, 2000; Westra,
Dozois, & Marcus, 2007). Even less research has been designed to evaluate therapist
in-session behaviors in facilitating client adherence to homework, and the results
have been inconsistent (i.e., Bryant, Simons, & Thase, 1999; Startup & Edmonds,
1994). An improved understanding of the day-to-day use of homework assignments
in clinical practice would seem like a useful step in advancing the evidence base.
The first aim of the present study was to gather data on practicing psychologists’
definitions of homework tasks and processes. Compared with psychodynamic
practitioners, it was hypothesized that practitioners of cognitive-behavioral therapy
(CBT) would consider homework to represent interventions from empirically
supported therapies (Hypothesis 1). As compared with their psychoanalytic
counterparts, it was also hypothesized that CBT practitioners would conceptualize
the process of using homework as a method of empowering clients (Hypothesis 2).
Empowerment through homework in the present study was operationalized as the
use of tailored assignments, placing an emphasis on client responsibility for change
and maintaining a focus on increasing adaptive skills.
The second aim of the present study was to gather data on the types of homework
assignments used in clinical practice. It was hypothesized that CBT therapists would
recommend more tasks that involve reading, monitoring, or other specific activity
components compared with psychoanalytic therapists (Hypothesis 3).
The third aim of the present study was to assess therapists’ beliefs about the
importance of homework assignments for clients presenting with a broad range of
problems. It was considered essential to survey perceived importance on theoretical
and empirical grounds. Decisions to utilize interventions are clearly related to their
perceived importance for patients. There is also preliminary evidence to suggest that
homework is considered less important in the treatment of delusions and
hallucinations, physical problems, and sexual abuse (Kazantzis & Deane, 1999).
Therefore, it was hypothesized that homework would be considered less important
for cases involving delusions and hallucinations, physical problems, and sexual abuse
as compared with other presenting problems (Hypothesis 4).
Journal of Clinical Psychology DOI: 10.1002/jclp
 Definitions, Types, and Importance of Homework 761

Method
Participants
A cover letter introducing the study, including a survey and a postage-paid return
envelope, were mailed to 3,000 randomly selected members of the American
Psychological Association (APA). The mailing labels were provided by the APA
research office with the conditions that psychologists were (a) resident in the United
States, (b) licensed by a particular jurisdiction, and (c) had indicated that the
provision of health and mental health services was their main activity in their primary
or secondary work setting. A reminder card was mailed to all participants 2 weeks
after the main mailing. A second copy of the survey was mailed to 1,200 randomly
selected recipients from the original 3,000 pool 4 weeks later. All responses were
completely anonymous and return envelopes were not coded and were destroyed
upon receipt. The only incentive to participate was a personal copy of the results,
which was to be requested under separate cover to protect anonymity. The return rate
of 28% yielded 840 replies and a total of 827 usable returns (Table 1). This was
comparable to previous psychologist surveys of practice and attitudes following the
same methodology (e.g., 30% response rate in Addis & Krasnow, 2000).

Survey Questionnaire
The phrase ‘‘between-session assignments’’ was used in place of the term ‘‘homework
assignments’’ to reduce therapist reactivity and conceal the CBT orientation of the
research team. As the present study was specifically designed to survey practitioners’
definitions of between-session assignments, an operational definition for a ‘‘between-
session assignment’’ was not provided. The questionnaire comprised 27 self-report
items assessing practitioners’ definitions, types, and perceived importance of
homework.
Definitions of homework. Practitioners were first asked about the extent to which
they agreed with seven definitions of homework (i.e., rate the extent that you believe
each of the following statements characterize between-session assignments). Given
that CBT has led the field in manualizing psychotherapy for empirical evaluation, we
expected that CBT practitioners would be more likely to define homework as
interventions from empirically supported therapies. Practitioners were also asked
whether the use of tailored assignments, having an emphasis on client responsibility
for change and maintaining a focus on increasing adaptive skills, met with their
definition of homework. Because it was possible that practitioners might select
homework from empirically supported treatment manuals or select predetermined
schedules of homework tasks, two final items were also devised to assess these
definitions. Table 2 contains the complete set of items. Agreement with definitions of
homework was rated on a 4-point Likert scale ranging from 1 (not at all
characteristic) to 4 (very characteristic).
Homework types. Practitioners were asked to indicate their use of 10 different
types of homework activities (i.e., please indicate how often you recommend the
following types of between-session activities). Therapists will also commonly suggest
that clients pay attention to a particular thought, make note of a certain kind of
experience, or try out a new behavior or activity during the week, and these activities
could represent homework tasks in a range of therapeutic models (Nelson et al.,
2007). The former is more of a command, the latter is more of a recommendation,
Journal of Clinical Psychology DOI: 10.1002/jclp
762 Journal of Clinical Psychology, July 2010

Table 1
Sample Characteristics

Variable % n M SD

Gender
Male 48 399
Female 51 418
Age (years) 52.43 9.63
Ethnicity
African-American 1 5
Asian-American 1 4
European-American/Caucasian 93 766
Hispanic/Latino 1 8
Native-American 1 8
Years since graduate degree 18.60 9.50
Degree
Masters 2 18
PhD 83 686
PsyD 9 74
EdD 4 32
Years in clinical practice 20.65 9.09
Percentage of annual caseload
Infants 01.06 03.73
Children 16.84 17.60
Adolescents 17.38 14.80
Adults 68.37 25.00
Older adults 11.52 12.34
Percentage of annual caseload
Individual 72.47 19.49
Group 10.00 14.05
Couple 16.37 11.80
Family 14.46 14.93
Predominant theoretical orientation
Behavioral 2 12
Cognitive-behavioral 39 324
Existential/humanistic 7 59
Social learning 1 9
Psychodynamic/analytic 24 200
Interpersonal 7 60
Family systems 3 28
Other 12 95

Note. M 5 mean; SD 5 standard deviation. Percentages may not equal 100 because multiple responses
were allowed. Some practitioners may have included internship/ practicum training in reporting years in
practice.

the difference relates to. Therefore, for the present study, questionnaire items were
constructed to evaluate differences in tasks based on both the nature and the
mechanics of undertaking the activity (e.g., whether the tasks involved some overt
action or recording). These items were constructed based on prototypical
assignments appearing in the literature (see Kazantzis & L’Abate, 2007). We
specifically avoided the use of terminology aligned with a particular therapy, and
instead used examples from different theoretical models in the questions, such as
‘‘monitor cognitions, including the use of dream diaries and daily thought records.’’
Similarly, we used the items ‘‘Read material relevant to therapy, psychoeducation or
self-help material’’ rather than the term ‘‘bibiotherapy.’’ The items ‘‘monitor
interpersonal interactions, such as social, couple, or familial interaction’’ and ‘‘think
Journal of Clinical Psychology DOI: 10.1002/jclp
 Definitions, Types, and Importance of Homework 763

Table 2
Practitioners’ Definitions of Homework

Cognitive-behavioral Psychodynamic

Definitions of homework M SD n M SD n

1. Interventions derived from empirically 2.71 .72 331 2.19 .72 246
supported psychotherapies
2. Tailored interventions that are part 3.10 .69 333 2.65 .79 249
of treatment plans
3. Emphasize enhanced communication 2.79 .80 331 2.47 .86 247
between client and therapist
4. Emphasize client responsibility for change 3.44 .60 334 3.01 .82 249
5. Conceptualize therapy as a process 3.37 .62 332 2.85 .78 248
of increasing adaptive skills
6. Components of treatment manuals 2.44 .86 328 2.16 1.04 235
7. A predetermined (prepackaged) schedule 1.75 .72 330 1.70 .85 240
of tasks and interventions

Note. M 5 mean; SD 5 standard deviation. Descriptive statistics are produced in boldface where subgroup
differences reached the criterion (d4.5). Practitioners rated their definitions on a 4-point Likert scale,
where 1 (not at all characteristic), 2 (somewhat characteristic), 3 (characteristic), and 4 (very characteristic).

about therapy goals or session events without any written component’’ were also
selected for their broad application and clear departure from traditional behavior
and cognitive therapy homework. Table 3 includes a complete list of content covered
in homework types questions.2 Use of homework types was rated on a 6-point Likert
scale ranging from 0 (never) to 5 (almost always).

Importance of homework. Practitioners were also asked to rate the importance of

homework for various client problems (i.e., please rate how important you believe
between-session activities are in the treatment of the following problems/disorders).
These items were designed to survey importance of homework for 19 disorders
covered in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition
(DSM-IV; American Psychiatric Association, 1994). Table 3 contains the complete
set of items. Importance of homework was rated on a 6-point Likert scale ranging
from 0 (not at all) to 5 (extremely).

Data Analysis
In very large samples, even small, conceptually meaningless differences will yield
rejections of the null hypothesis when significance testing is employed (see Orlinsky
& Rønnestad, 2005). Practitioner surveys have instead compared means using effect
sizes (ES) to evaluate subgroup differences (Elliot, Stiles, & Shapiro, 1993). This
analytic approach involves the comparison of subgroups based on means (M) and
standard deviations (SD; Orlinsky et al., 1999). In the present study, Cohen’s d 4.5
was used as the criterion for a medium sized difference between subgroups (Cohen,
1988). Only results that meet this criterion for a meaningful difference are
highlighted in the results description and discussion sections below.
2
Readers A copy of the questionnaire is available upon request from the corresponding author.

Journal of Clinical Psychology DOI: 10.1002/jclp

764 Journal of Clinical Psychology, July 2010

Table 3
Practitioners’ Use of Different Types of Homework

Cognitive-behavioral Psychodynamic

Homework activity M SD n M SD n

1. Read material relevant to therapy, or psychoeducation 3.35 .93 334 2.77 .97 246
2. Monitor cognitions (e.g., dream diaries, thought records) 3.44 .89 335 3.09 .99 247
3. Monitor behavior (e.g., food intake, daily activities) 3.28 .83 334 2.74 .99 246
4. Monitor interpersonal interactions (e.g., couple, family) 3.28 .93 335 3.29 .89 245
5. Monitor emotions, including subjective intensity ratings 3.25 .95 335 2.99 .99 245
6. Monitor physiological changes (e.g., panic attacks) 2.96 1.02 335 2.72 1.08 243
7. Complete measures of therapy outcome or process 1.98 .91 332 1.51 .76 243
8. Test thoughts or assumptions (e.g., behavioral experiments) 2.87 1.02 334 2.03 .97 243
9. Think about therapy goals or session without writing 3.30 1.04 335 3.14 1.10 242
10. New behavior (e.g., pleasure or mastery) 3.55 .88 334 2.99 1.01 244

Note. M 5 mean; SD 5 standard deviation. Descriptive statistics are produced in boldface where pairs of
subgroup differences reached the criterion (d4.5). Practitioners rated use of homework on a scale ranging
from 1 (never) to 5 (almost always).

Results
Sample Characteristics
Demographic characteristics of the sample (N 5 827) are presented in Table 1. The
majority of practitioners (92%, n 5 760) in the sample indicated that their
professional time was spent in direct clinical work (68% of their caseload were
adults). Forty-eight percent were male and 93% of respondents were Caucasian. The
mean age of respondents was 52.43 years (SD 5 9.63). In terms of professional degree,
83% had earned a PhD degree, 9% had earned a PsyD degree, 4% had earned an
EdD degree, and 2% had earned a Masters degree. Respondents had reported an
average of 20.65 years (SD 5 9.09) practical experience (including training experience)
and had completed graduate school an average of 18.60 years (SD 5 9.51). Seventy-
six percent of respondents identified their primary area of specialization as clinical
psychology, 18% with counseling psychology and 2% with school psychology.
To evaluate the representativeness and appropriateness of the present sample, we
compared respondents’ demographic and clinical characteristics with the total APA
membership (APA Research Office, 2000). The present sample was virtually identical
to the APA membership in terms of gender, age, ethnicity, number of years in
clinical practice, and professional degree. A greater proportion of the present sample
(92%) reported clinical work as their primary professional activity compared with
the APA membership (i.e., 27% of total APA membership and 50% of full-time
employed APA members). Similarly, more practitioners in the present sample (72%)
were independent practitioners compared with the APA membership (i.e., 15% of
total and 34% of full-time employed APA members). As the present sample was
specifically selected to be representative of psychologists who use homework in clinical
practice, these differences support the external validity of the study.
The mean percentage of respondents annual caseload across therapy formats was
72% (SD 5 19) for individual therapy, 16% (SD 5 12) for couples therapy, 14%
(SD 5 15) for family therapy, and 10% (SD 5 14) for group therapy. Respondents
reported treating mostly adults (68% of yearly caseload, SD 5 25), followed by
Journal of Clinical Psychology DOI: 10.1002/jclp
 Definitions, Types, and Importance of Homework 765

adolescents (17%, SD 5 15), children (17%, SD 5 18), older adults (12%, SD 5 12),
and toddlers (1%, SD 5 4).
In terms of theoretical orientation, respondents self-identified with CBT (41%),
psychodynamic/analytic therapy (25%), existential/humanistic therapy (8%), inter-
personal therapy (8%), family systems therapy (4%), behavioral therapy (2%),
social learning therapy (1%) and other therapies (integrative/eclectic; 12%). The
range and percentages of theoretical orientations was similar to APA members
(Division 12; Norcross, Karg, & Prochaska, 1997). Given the prominence of the
cognitive-behavioral and psychodynamic/analytic approaches in the sample, all
further analyses of theoretical orientation involved behavioral (n 5 12), cognitive-
behavioral (n 5 324), and social learning (n 5 1) combined in the category
‘‘cognitive-behavioural.’’ Psychodynamic/analytic (n 5 200) and interpersonal ther-
apy (n 5 60) practitioners were combined in the category ‘‘psychodynamic.’’ As
remaining therapists represented a small heterogenous subgroup, analyses were
focused on contrasting CBT and psychoanalytic subgroups.

Definitions of Homework
In the overall sample, some definitions were rated as less characteristic of homework,
namely, ‘‘a predetermined (prepackaged) schedule of tasks or interventions’’
(M 5 1.69; SD 5 .76). Other definitions showed consistent differences in definitions
of homework as a function of theoretical orientation. (Only mean differences that
meet the criterion d4.5 for a meaningful difference between subgroups in relation to
the overall sample are highlighted.)
Four items were identified as being ‘‘more characteristic’’ of homework by CBT
practitioners and simultaneously rated as ‘‘less characteristic’’ by psychodynamic
practitioners when compared to the overall sample. Specifically, CBT and
psychodynamic practitioners differed in their definitions of homework as being
derived from empirically supported therapies (M 5 2.71, M 5 2.19, respectively), as
being tailored interventions in treatment plans (M 5 3.10, M 5 2.65, respectively), as
emphasizing client responsibility for change (M 5 3.44, M 5 3.01, respectively), and
as conceptualizing therapy as increasing adaptive skills (M 5 3.37, M 5 2.85,
respectively). It was also noteworthy that the entire sample agreed that assigning
homework is somewhat characteristic of enhanced client-therapist communication
and represents a component of treatment manuals. Subgroups also agreed with the
overall sample that homework was not characteristic of a predetermined schedule of
tasks (see Table 2). These findings supported Hypotheses 1 and 2.

Use of Different Types of Homework

In the overall sample, almost all types of homework assignments were reported as
being used at least sometimes. Four tasks were used less often, namely, monitoring
physiological changes (M 5 2.84; SD 5 1.04), completing measures of therapy
outcome or progress (M 5 1.79; SD 5 .87), and testing validity of thoughts or
assumptions (M 5 2.51; SD 5 1.06). Once again, there were systematic differences
between practitioners as a function of their theoretical orientation.
Five types of homework were more commonly used by CBT practitioners and
simultaneously less commonly used by psychodynamic practitioners. Compared with
the overall sample, CBT and psychodynamic practitioners differed in their use of
reading material (M 5 3.35, M 5 2.77, respectively), monitoring behavior (M 5 3.28,
M 5 2.74, respectively), testing thoughts (M 5 2.87, M 5 2.03, respectively), and
Journal of Clinical Psychology DOI: 10.1002/jclp
766 Journal of Clinical Psychology, July 2010

engaging in new behavior (M 5 3.55, 2.99, respectively). Although there were also
consistent differences in CBT and psychodynamic therapists’ use of outcome or
process measures, both groups rated this as a less popular homework task (M 5 1.98,
M 5 1.51, respectively). Contrary to our a priori Hypothesis 3, there were no
consistent differences between CBT and psychodynamic therapists in monitoring
thoughts, interpersonal interactions, emotions, physiological changes, or thinking
about therapy goals (see Table 3).

Importance of Homework Assignments

In the overall sample, homework was considered less important in the treatment of
cognitive disorders (M 5 2.16; SD 5 1.11), pervasive developmental disorders
(M 5 2.79; SD 5 1.30), schizophrenia and psychotic disorders (M 5 2.40;
SD 5 1.06), sexual or gender identity disorders (M 5 2.85; SD 5 1.17), and tic
disorders (M 5 2.85; SD 5 1.22). These results supported Hypothesis 4.
CBT practitioners and psychodynamic practitioners differed in their ratings of the
importance of homework for broad range of patient problems. Compared with the
overall sample, there were large differences in importance ratings by CBT
practitioners, who considered homework more important for anxiety, mood, and
relational problems. Psychodynamic practitioners rated homework’s importance
substantially less for adjustment, anxiety, mood, and relational problems. Consistent
with the overall sample, both subgroups agreed that homework was less important
for developmental, cognitive, and psychotic disorders. There was also agreement
that homework was more important for attention deficit and substance abuse/
addiction (see Table 4).

Table 4
Practitioners’ Perceived Importance of Homework Assignments

Cognitive-behavioral Psychodynamic

Disorder M SD n M SD n

1. Adjustment 3.63 .92 331 2.91 1.04 246

2. Anxiety 4.49 .66 335 3.62 1.07 250
3. Attention deficit, disruptive 3.80 1.08 315 3.32 1.15 230
4. Delirium, dementia, cognitive 2.30 1.14 301 1.97 1.08 224
5. Eating 4.25 .78 321 3.64 1.04 243
6. Elimination 3.85 1.05 285 3.18 1.17 207
7. Impulse control 4.24 .82 327 3.63 1.11 243
8. Learning 4.18 .85 318 3.66 1.01 235
9. Mood 4.03 .84 334 3.12 1.06 247
10. Personality 3.32 1.13 329 2.61 1.21 247
11. Pervasive developmental 2.85 1.30 280 2.64 1.30 213
12. Physical illness and rehabilitation 3.09 .99 307 3.67 1.08 229
13. Relational problems 4.16 .75 325 3.45 1.11 242
14. Schizophrenia, psychotic 2.55 1.04 298 2.21 1.11 225
15. Sexual and gender identity 3.15 1.15 302 2.44 1.12 232
16. Sleep 4.08 .89 320 3.42 1.07 239
17. Somatoform 3.37 1.09 298 2.79 1.10 219
18. Substance abuse, addiction 4.29 .93 321 3.86 1.16 234
19. Tic 3.08 1.21 290 2.51 1.20 205

Note. M 5 mean; SD 5 standard deviation. Descriptive statistics are produced in boldface where subgroup
differences reached the criterion (d4.5). Practitioners rated their perceived importance on a scale ranging
from 0 (not at all important) to 5 (extremely important).

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 Definitions, Types, and Importance of Homework 767

Discussion
The issues of how to define homework assignments has been a challenge for theorists
and researchers of psychotherapy for some time. Systematic reviews of the literature
have noted that a range of terms have been used to refer to homework (e.g.,
Kazantzis, 2000) and there are different conceptualizations in different models of
treatment (Nelson et al., 2007). Researchers have also called for a better definition of
homework should future empirical investigations focus on its effects beyond the
context of CBT (Lambert et al., 2007). Consequently, the present study was designed
as an initial step in responding to this call. It was considered potentially useful to
survey practicing psychologists who use homework within different theoretical
models and ask about their definitions of homework, use of different types of
homework, and views of the importance of homework for different problems.
Homework is a structural aspect of psychotherapy that can be routinely integrated
into treatment sessions. The potential exists for practitioners to consistently use the
same homework tasks for certain patient populations. The present sample agreed
that homework is not defined as a predetermined or prepackaged schedule of tasks
or interventions. The sample also agreed that homework can be defined as a
component of treatment manuals and represent an opportunity for enhanced
patient-therapist communication. At the same time, there were consistent differences
between CBT and psychodynamic therapists in their homework definitions. CBT
practitioners rated homework as being closer to empirically supported therapies and
part of tailored treatment plans. Psychodynamic therapists rated homework as being
less characteristic of a process that enhances client responsibility and adaptive skills.
A sample of 827 cannot be considered truly representative of the entire population of
practitioners who use homework. However, it is possible that these differences in
definition are a true reflection of the different ways in which homework is
conceptualized or integrated into practice by psychologists in this study. The manner
in which the homework is defined, planned, and reviewed in-session cannot be
interpreted without considering what types of activities are being used.
It is noteworthy that there was consistency in the sample regarding the use of
several types of homework assignments. Homework assignments that involved
patients’ monitoring of cognitive content, such as dreams and conscious thoughts,
were used at least ‘‘sometimes’’ by the entire sample. Similarly, monitoring
interpersonal interactions, emotions, physiological reactions, and thinking about
session goals were used on occasion. CBT and psychodynamic subgroups did not
differ in their use of these types of homework to the overall sample. The entire
sample also rated the use of psychometric measures as the least frequently used
homework activity. When psychometric measures are taken away from the
consultation setting for homework, control over access, interpretation, and accurate
recording of raw psychometric data emerge. There are also clear ethical issues that
may arise should the data become lost or stolen. The present sample reported
‘‘rarely’’ or ‘‘never’’ using psychometric measures as a type of homework.
A pattern also existed between CBT and psychodynamic therapists’ use of
different homework tasks. CBT practitioners were more likely to use reading
material or activities that involved some behavior (i.e., monitoring behavior, testing
thoughts or assumptions through behavioral experiments, or engaging in a new
behavior). This finding is consistent with the manner in which homework has been
traditionally defined in the behavioral and CBT literature, that is, homework is
conceptualized to involve some overt activity. However, it should be noted that the

Journal of Clinical Psychology DOI: 10.1002/jclp

768 Journal of Clinical Psychology, July 2010

similarities in the present data suggest that CBT practitioners do not limit their use
of homework to activity-based homework. It is also worth noting the psychody-
namic therapists also reported the use of behavioral activities as homework
‘‘sometimes’’ on the average.
These data suggest that at least some types of homework tasks may be common to
different psychotherapeutic approaches. These findings are important because a
frequently held belief is that homework is not characteristic of psychodynamic and
psychoanalytic therapies (Blagys & Hilsenroth, 2002). It also supports recent
theoretical discussion and clinical practice illustration regarding the use of
homework in various therapy approaches. Several theorists have argued that the
therapeutic use of the time between sessions is less different (between therapy
models) in clinical practice and more different in terms of the terminology in the
extent to which the process is systematically integrated into sessions (Garfield, 1997;
Kazantzis & Ronan, 2006; Stricker & Gold, 1996). The present study is the first to
provide data to evaluate such assertions.
The present study also replicated a previous finding regarding practitioners’ perceived
importance of homework assignments for different patient problems. Practicing
psychologists in the present sample residing in North America rated homework as
less important in therapy for cognitive disorders, pervasive developmental disorders,
schizophrenia/ psychotic disorders, sexual or gender identity disorders, and involuntary
movement disorders. These results were similar to a limited sample of practicing
psychologists in New Zealand (N 5 221, Kazantzis & Deane, 1999). At the same time,
CBT and psychodynamic subgroups demonstrated disagreement regarding their ratings
of homework’s importance. Psychodynamic therapists rated homework as ‘‘somewhat’’
or ‘‘moderately’’ important for most problems, whereas CBT therapists often rated
homework as being ‘‘very’’ important. These data suggest that psychodynamic
therapists consider homework less important overall.
It would be premature to draw any firm conclusions about the actual importance of
homework within these therapeutic approaches. The existing data on homework’s
effects have addressed two issues: the ability for homework to increase therapy
outcome and the association between homework compliance and symptom reduction.
However, this literature is currently limited to studies of behavioral and cognitive
therapies (Kazantzis, Whittington, & Dattilio, in press). As the present study indicates,
psychologists are aligned with the recommendations of theoreticians. Therefore, it
would seem that the recent call for research on homework effects in insight-oriented
therapy and other models of psychotherapy can be underscored (Lambert et al., 2007).
Research is currently lacking to support the use of homework in such models.
There were important methodological limitations with the present study that
should be acknowledged. One limitation was the modest response rate of 28%.
Although prior studies seeking to conduct surveys of practicing psychologists have
obtained similar rates (e.g., Addis & Krasnow, 2000), and the present sample was
similar in demographic characteristics to the total APA membership, the sample may
still have been biased in some way. For instance, it is possible that individuals
choosing to participate in the study may have had a particular interest in
psychotherapy research (i.e., there was a high proportion of clinicians with doctoral
level training). It should also be noted that the present study was specifically
interested in sampling psychologists who use ‘‘between-session’’ or homework
assignments in their clinical practice. There is insufficient current information
regarding the population of psychologists who use homework, and whether they are
different from the broader practicing psychologist population.
Journal of Clinical Psychology DOI: 10.1002/jclp
 Definitions, Types, and Importance of Homework 769

The present study also involved a survey questionnaire that was designed by a
CBT research team. The research methodology was cross-sectional and relied
exclusively on self-report to fixed items that had different therapeutic aims. For
instance, the cognitive monitoring homework exercise included in the present study’s
questionnaire had ‘‘monitor dreams’’ and ‘‘conscious thoughts’’ in the same item.
Thus, the present study secured only practitioners’ self-reported use of these
homework types and missed how practitioners used these homework tasks in the
service of theoretically distinct mechanisms of change. However, there was a high
degree of consistency in the findings by theoretical orientation. Among the 827
therapists sampled, CBT and psychodynamic therapists consistently differed in (a)
the extent to which they considered our items to represent definitions of homework,
(b) the extent to which they used the different types of homework we outlined, and
(c) how important they considered homework for a range of different problems we
listed in the questionnaire. However, there was also marked agreement between
subgroups and the overall sample. A completely open-ended questionnaire may have
revealed further differences and consistencies and reduced the possibility of a social
desirable or other set response fashion.

Recommendations for Future Research

Our research technologies are far from reaching the point where the complexities and
richness of human interaction present in a therapy session are being fully appreciated
and understood. Similarly, we are a long way from detecting theoretically
meaningful markers of change in many psychotherapies (Kazantzis, Reinecke, &
Freeman, 2010). The present study found that practitioners of different self-
identified psychotherapy models use various types of homework tasks to promote
positive therapeutic change for their clients. This finding supported the assertion that
the techniques of psychotherapy do not define the psychotherapy (Goldfried, Raue,
& Castonguay, 1998; Thoma & Cecero, 2009). The findings were consistent with
earlier, less extensive surveys (Kazantzis, Busch, Ronan, & Merrick, 2006) and recent
discussions in the theoretical integration movement (Kazantzis & Ronan, 2006;
Nelson et al., 2007). The study also supported the published case studies of diverse
psychotherapies that have emphasized the role of between-session tasks (Beck &
Tompkins, 2007; Ellison & Greenberg, 2007; Neimeyer & Winter, 2007; Twohig,
Pierson, & Hayes, 2007; Robbins, Szapocznik, & Perez, 2007; Roth Ledley &
Huppert, 2007; Witty, 2007; Young & Mufson, 2007). However, due to the lack of
empirical work to support these practices, we offer several suggestions for potentially
fruitful avenues of research for a finer-grained evaluation of homework in
psychotherapy.
It would be helpful to have a better understanding of the representative process
taken to integrate homework in different therapy models. If homework is
semiregularly or routinely discussed by a practitioner of dialectical behavior therapy
or encouraged in a broad sense by a practitioner of acceptance and commitment
therapy, then it would be useful to know how these discussions are initiated and
pursued by therapists. The process for reviewing any attempt towards between-
session practice of homework would also be interesting to consider. Ideally, such
research would involve direct observations of therapists who are adherent to the
particular theoretical model, and competent in its delivery, as an initial step in this
endeavor. Factors such as training (i.e., masters vs. doctoral level) would also be
worthwhile considerations in such research.
Journal of Clinical Psychology DOI: 10.1002/jclp
770 Journal of Clinical Psychology, July 2010

It would also be helpful to better understand the distinction and overlap between
adherence with homework and learning from homework. It is clear in the research
that has been conducted on homework effects in the behavior and cognitive therapies
that the degree of skill acquisition, or quality of homework completion, is a better
correlate of symptom change than the quantity of homework completion (Kazantzis
et al., in press). Before research can be conducted on the utility of homework as a
determinant of meaningful clinical change in different therapy models, it will be
important to define what comprises useful learning, deepening of insight,
strengthening of relationship, or other aims of the particular homework assignment.
Clearly, constructing different methods of evaluating the specific learning from
different homework assignment will be a major undertaking.
A final suggestion we offer for future research concerns the links among the case
formulation, therapeutic relationship, and selection of homework tasks. As has been
highlighted in this article, simply selecting a particular homework assignment (e.g.,
thought record) does not mean that a therapists’ practice is adherent with the tenets
of any particular therapeutic model. Thus, the link among the hypothesized
mechanisms of change in the specific therapeutic model, how those mechanisms are
operationalized in a formulation and treatment plan, would benefit from further
clarification. Similarly, the role of the therapeutic relationship as a curative and
facilitative condition for therapeutic change would be worthy of empirical evaluation
in the context of using homework. A collaborative therapeutic quality may, for
instance, be commensurate with a therapist’s intention to be active in the session,
encouraging of patient experimentation through in-session practice, and soliciting of
client feedback about a task that could be used for homework. There are, however,
many aspects of this example that are inconsistent with the therapeutic relationship
intended in traditional forms of less ‘‘directive’’ therapies. Therefore, we encourage
process researchers to consider focus on the case formulation, therapeutic relation-
ship, and integration of homework as overlapping and interactional, rather than as
distinct processes in therapy.

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