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1. Clinical Psychology and Psychotherapy
Clin. Psychol. Psychother. 332–343
Copyright © 2004 John Wiley & Sons, Ltd.
Published online 3 September 2004 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/cpp.419
Attitudes and Use of Homework
Assignments in Therapy: A Survey
of German Psychotherapists
Lydia Fehm1
and Nikolaos Kazantzis2
*
1
Dresden University of Technology, Germany
2
Massey University, New Zealand
There has been continued empirical research on the role of homework
assignments in psychotherapy, but little is known about their use in
clinical practice. Although attitudes are an important factor in deter-
mining whether practitioners use homework assignments, existing
data is limited to the frequency and types of assignments used in
therapy. One hundred and forty German psychologists were surveyed
regarding their use of and attitudes towards homework assignments.
Practitioners reported a variety of attitudes regarding the effects of
homework on treatment outcome, the process of integrating home-
work into therapy and patient compliance with homework. We
suggest that consideration should be given to therapist attitudes (or
beliefs) in future conceptual or empirical work designed to examine
homework effects in psychotherapy. Copyright © 2004 John Wiley &
Sons, Ltd.
*Correspondence to: Nikolaos Kazantzis, Ph.D., School of
Psychology, Massey University (Albany Campus), Private
Bog 102904, NSMC, Auckland, New Zealand.
E-mail: N.Kazantzis@massey.ac.nz
The therapeutic use of activities (or homework
assignments) between therapy sessions to gather
information, practice skills or apply insights
gained in therapy is probably as old as therapy
itself. Although popularized within early formula-
tions of behavioral and cognitive psychotherapies
(Dunlop, 1936; Herzberg, 1941; Kanfer & Phillips,
1966; Kelly, 1955), it is traditional practice for psy-
chodynamic practitioners to ask their patients to
remember their dreams, possibly even write them
down for in-session discussion and analysis
(Freud, 1999; Stricker, in press). This type of
information gathering is commonplace in
cognitive–behavioral therapy (Beck, Rush, Shaw, &
Emery, 1979), even though the specific content and
in-session process for using the assignment may
be different between therapeutic approaches (see
also the spring 2000 issue of Journal of Cognitive
Psychotherapy).
Given this similarity in psychotherapy process, it
has been argued that acquisition of adaptive skills
through work completed between sessions repre-
sents a common attribute of both cognitive and
dynamic therapies (Badgio, Halperin, & Barber,
1999). More recently, a special issue of the Journal
of Psychotherapy Integration provided a theoretically
focused discussion of between-session (home-
work) assignments in the range of psychothera-
pies, which included case examples from
behavioral, client-centered, cognitive–behavioral,
emotion-focused experiential, interpersonal, psy-
chodynamic, and systems-orientated individual
therapy (see Kazantzis & Ronan, in press).
Homework assignments have continued to
receive emphasis in practitioner-orientated discus-
sions of cognitive–behavioral therapy for anxiety
(see, e.g. Leahy, 2002), depression (see, e.g. Garland
& Scott, 2002), schizophrenia (see, e.g. Glaser,
Kazantzis, Deane, & Oades, 2000), as well as other
patient problems and populations (see the special
issue of the Journal of Clinical Psychology, Kazantzis
& Lampropoulos, 2002). This continued emphasis
has been paralleled in empirical research where
correlational studies have repeatedly shown that

2. Attitudes and Use of Homework Assignments 333
Copyright © 2004 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 11, 332–343 (2004)
homework compliance is associated with therapy
outcome for depression (Fennell & Teasdale, 1987;
Burns & Spangler, 2000) and anxiety (Al-Kubaisy,
Marks, Logsdail, & Marks, 1992; de Araujo, Ito,
Marks, & Deale, 1995; Edelman & Chambless, 1993;
Leung & Heimberg, 1996; Schmidt & Woolaway-
Bickel, 2000).
Similarly, the experimental research has shown
that behavioral and cognitive–behavioral therapies
involving homework assignments produce greater
treatment outcomes than therapies comprising
entirely in-session work (see, e.g. Neimeyer &
Feixas, 1990), although the findings have not been
published without controversy over interpretation
of results (see, e.g. Zettle & Hayes, 1987; Kornblith,
Rehm, O’Hara, & Lamparski, 1983) and method-
ological limitations (see Kazantzis, 2000; Kazantzis,
Deane, & Ronan, in press; Kazantzis, Ronan,
& Deane, 2001). A meta-analysis (i.e. Kazantzis,
Deane, & Ronan, 2000) aggregated this research in
support of the notion that homework enhances
treatment outcome, and these findings have since
been extended in recent treatment outcome
studies of obsessive–compulsive disorder (i.e.
Abramowitz, Franklin, Zoellner, & DiBernardo,
2002), and depression among older adults (Coon &
Thompson, 2003).
Despite the emphasis in theoretical discussions
and empirical work, very little is known about
practitioners’ use of homework in everyday clini-
cal practice. One early study reported by Shelton
and Levy (1981a) examined the use of homework
assignments in treatment outcome studies pub-
lished from January 1973 to January 1980 in eight
scholarly journals. They reported that 68% of the
articles described the use of homework assign-
ments to promote treatment gains. Homework was
most commonly assigned for social skills training
(80%), obsessive–compulsive symptoms (79%),
and sexual dysfunction (79%). A subsequent
survey of published research by Mahrer, Nordin,
and Miller (1995) demonstrated that homework
assignments have continued to be incorporated as
components of manualized treatment protocols
across most problem areas. However, given that
these estimates of homework use are based on
reviews of published research articles, it is ques-
tionable whether these estimates can be general-
ized to clinical practice.
Warren and McLellarn (1987) surveyed the use
of homework in the therapeutic practices of 144
qualified rational–emotive therapists. The study
showed that a wide variety of bibliotherapy,
writing, and activity assignments were generally
used among practitioners. Despite reporting the
types of homework activity prescribed, the study
did not examine the overall frequency of home-
work use among therapists.
Petheram (1992) surveyed patient performance
and therapist attitude toward home-based treat-
ment of aphasia. This study showed that patients
were willing to engage in the home-based form of
treatment, and that psychologists were enthusias-
tic about the home-based approach (see also
Petheram, 1994). However, once again, the
Petheram (1992) study was not designed to assess
the frequency of homework use in clinical practice.
Kemmler, Borgart, and Gärke (1992) surveyed a
general psychologist sample on their use and per-
ceived importance of homework assignments (N =
61). The sample reported a range of theoretical
backgrounds, but the vast majority (87%) rated
homework as either important or extremely impor-
tant for their practice of therapy. This study also
provided preliminary evidence to suggest that
practitioners do not use a predetermined list of
homework assignments, with only 25% of the
sample sometimes designing homework before the
therapy session.
Kazantzis and Deane (1999) also surveyed a
general psychologist sample on the use of home-
work assignments in clinical practice (N = 221). The
study demonstrated that homework assignments
were frequently assigned by the majority of psy-
chologists (98% reported homework use). A differ-
ence in the types of assignments and in-session
processes used to assign homework was observed
between practitioners of different theoretical ori-
entations in their sample. That is, those reporting
a cognitive–behavioral orientation tended to assign
homework activities that involved specific record-
ing more frequently, and tended to follow theoret-
ical recommendations (i.e. Shelton & Levy, 1981b)
for assigning homework more consistently than
their counterparts. The study was limited in that
the study was conducted in New Zealand, and the
study was not designed to survey practitioners’
attitudes or the extent to which their attitudes were
related to the use of homework.
There is a dearth of data on how practitioners feel
about the use of homework assignments in psy-
chotherapy. Regardless of demonstrated empirical
support for homework assignments, or the degree
of motivation of the individual patient, it is the
practitioner who determines whether homework
assignments are actually integrated into the every-
day treatment of mental illness and who will ulti-
mately determine whether homework assignments

3. 334 L. Fehm and N. Kazantzis
Copyright © 2004 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 11, 332–343 (2004)
actually make helpful contributions to the services
that clients receive. Not surprisingly, some practi-
tioner training programs emphasize the important
role of therapist attitudes and beliefs in deter-
mining whether a therapeutic procedure will be
successfully integrated into therapy (see, e.g.
Padesky, 1999), and there is emerging data to
suggest that practitioner beliefs are linked with
particular aspects of clinical practice (see Addis &
Krasnow, 2000, for example).
The present study was designed to extend the
existing knowledge about the use of homework
assignments in clinical practice by conducting a
preliminary survey of practitioners’ use and atti-
tudes towards homework assignments. Given the
traditional emphasis of homework within behav-
ioral and cognitive–behavioral therapies, and the
results of prior studies of homework in clinical
practice (i.e. Kazantzis & Deane, 1999), we hypoth-
esized that practitioners working within these
theoretical approaches and those working in
university research settings would report a greater
use of homework assignments (Hypothesis 1). We
assumed that those working in university research
settings would be more up to date with current
research supporting cognitive–behavioral therapy
as an empirically supported therapy, and the liter-
ature on integrating homework assignments into
psychotherapy. In addition, we hypothesized
that those identifying with cognitive–behavioral
therapy and those working in the university
setting would use a greater number of homework
assignments (Hypothesis 2), be more systematic in
their review of homework assignment (Hypothesis
3), and have more positive attitudes towards the
role of homework assignments in psychotherapy
(Hypothesis 4). We also hypothesized that those
practioners who were more experienced psy-
chotherapy practitioners, and thereby more skilled,
would have more positive attitudes about home-
work (Hypothesis 5). Finally, we predicted that
those practitioners who had experienced difficul-
ties with patient completion of homework assign-
ments (or compliance) would have more negative
attitudes to homework (Hypothesis 6).
METHOD
Sample Characteristics
One hundred and forty practicing psychothera-
pists (age range 25–61 years, M = 40 years, SD =
8.5) participated in the survey. Thirty-nine percent
of practitioners were male (n = 55), and 61% were
female (n = 85). In terms of professional training,
72% of respondents had a PhD in psychology, and
27% had a degree in medicine.1
There was a broad
spectrum of therapy experience in the sample; 29%
reported 1000 hours experience or less, 11%
reported 1000–2000 hours, 14% reported 2000–4000
hours, 21% reported 4000–7000 hours and 23%
reported 7000 hours or more. (Following the imple-
mentation of psychotherapy law in 1999, and at
the time of this study, practicing psychologists
were required to document their clinical experi-
ence in treatment hours as standard procedure
in Germany.) All respondents were in at least part
time current psychotherapy practice. The propor-
tion of weekly work time spent providing therapy
was relatively high (M = 69%, SD = 31.2), with out-
patient and university settings featuring as the pre-
dominant work settings for this sample (69 and
21% of respondents, respectively).
In terms of theoretical orientation, the two most
common self-described approaches were cogni-
tive–behavioral therapy (64%) and ‘depth psychol-
ogy’ or psychodynamic/analytic psychotherapy
(26%), with the remainder of the sample (9%)
reporting a combination of approaches (e.g. inte-
gration of cognitive–behavior therapy and
psychoanalytic psychotherapy; cognitive–behavior
therapy and Gestalt psychotherapy). However,
there was a systematic difference in theoretical ori-
entation among practitioners with different profes-
sional trainings. Those practitioners with medical
training were predominantly psychoanalytic in
orientation (90% of medically trained sub-sample),
whereas psychology trained practitioners were
predominantly cognitive–behavioral in orientation
(92% of psychology trained sub-sample). Given the
large extent of theoretical purism (and lack of the-
oretical integration or eclecticism) among the prac-
titioners in the sample, as well as the systematic
difference in professional training among practi-
tioners of different theoretical orientations, all
further analyses involved comparison of cogni-
tive–behavioral and psychoanalytic practitioners.
(Cognitive–behavioral practitioners did not differ
in therapy experience to their psychoanalytic coun-
terparts, c2
(5, N = 123) = 5.39, p > 0.05.)2
1
In Germany, psychologists receive a PhD in psychology
either within the faculties of natural or philological science,
depending on the departmental association in the respective
university.
2
Proportions of less and highly experienced practitioners
practicing cognitive–behavioral therapy were similar (i.e. 43
and 41%, respectively), whereas there was a more experi-
enced representation among psychoanalytic approaches (i.e.
32 and 51%, respectively.).

4. Attitudes and Use of Homework Assignments 335
Copyright © 2004 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 11, 332–343 (2004)
Survey Questionnaire
We developed a survey questionnaire consisting of
31 self-report items assessing practitioners’ demo-
graphic characteristics, use of homework assign-
ments and attitudes towards the use of homework
assignments in psychotherapy. Demographic items
included age, gender, type of advanced degree,
theoretical orientation, clinical experience and
employment setting.
Items assessing use of homework assignments
included the following: (i) ‘On average, for what
proportion of patients do you use homework
assignments?’; (ii) ‘On average, in what proportion
of therapy sessions do you assign homework? and
(iii) ‘Do you assign homework during the first five
sessions?’.3
The questionnaire also included items
designed to assess the general types of homework
activity used by practitioners (i.e. ‘Which types of
assignment do you use?’), where respondents indi-
cated their use of different activities by endorsing
the categories ‘behavioral experiments, ‘self-
monitoring’, ‘cognitive restructuring’ and ‘apply-
ing new skills or techniques’. Frequency of
homework review was assessed by the item ‘Do
you review the completion of assignments?’ rated
on a 0–3 scale (0 = hardly ever, 1 = rarely, 2 = mostly,
3 = always). In addition, barriers to the effective use
of homework in psychotherapy were assessed (i.e.
‘What types of problem do you experience with
homework assignments?’), where respondents
indicated the difficulties by endorsing the cate-
gories ‘too difficult to the patient’, ‘unclear to
the patient’, ‘not beneficial for therapy’, as well
as ‘patients do not complete the homework as
assigned’ and ‘patients do not complete the home-
work at all’. Practitioners who did not use home-
work assignments were asked to ignore questions
on homework use and proceed to the attitudes
section.
Items assessing attitudes towards homework
assignments were generated from the authors’
own experience and from informal discussions
with practitioners. Items were designed to assess
practitioners’ attitudes regarding the effects of home-
work on treatment outcome (six items, such as ‘there
is a lack of empirical support regarding the posi-
tive effects of using homework in therapy’, ‘home-
work assignments are indispensable, the most
important changes occur outside the therapy
room’, ‘homework assignments always enhance
therapy outcomes’), the process of integrating home-
work into therapy (five items, such as ‘the term
“homework” is deterring/discouraging’, ‘the ther-
apist should make a note of the assignment’ and
‘therapists and patients should always design
assignments together’), as well as more specific
areas of attitudes regarding patients’ homework com-
pliance (two items, ‘the majority of patients reject
all homework assignments’ and ‘patient home-
work compliance is very poor’). An attempt was
made to balance the representation of positive and
negative attitudes. Practitioners rated their agree-
ment with these items on a five-point Likert scale
ranging from (0 not at all) to 4 (completely agree).
Four items assessing attitudes towards home-
work were excluded from data analysis, as they
did not achieve minimum criteria for item diffi-
culty, below the recommended value of 0.20 (see
Bortz & Döring, 1995, p. 199).4
Item–total correla-
tions for the remaining 13 attitude items ranged
between -0.01 and 0.43, the coefficient alpha was
0.60 and the mean score for the sample was 28.6
(SD = 6.1). We did not attempt an exploratory
factor analysis for attitude items because the
present sample size was less than is generally rec-
ommended for this procedure (see Cattell, 1978;
Comrey & Lee, 1973; Hair, Anderson, Tatham, &
Black, 1995).
Procedure
Participation was solicited at three advanced train-
ing seminars for psychotherapy in Germany. These
seminar were ‘Workshop-Kongress für Klinische
Psychologie’ in Bad Duerkheim, May 1999 (n =
83 respondents), ‘Verhaltenstherapiewoche’ in
Dresden, August 1999 (n = 13 respondents) and
‘Psychotherapietage’ in Luebeck, October 1999 (n =
44 respondents). Questionnaires were positioned
next to registration desks at these seminars, openly
accessible for all participants. Participation in the
study was voluntary, anonymous and without
compensation. Practitioners were encouraged to
participate in the study by a small notice added
to seminar documents, and return completed
3
German health insurance companies typically provide five
therapy sessions as a minimum amount.
4
Excluded items were ‘homework assignments in therapy
are a waste of time’, ‘homework assignments don’t match
my personal style in therapy’, ‘homework assignments just
create resistance in the patient’, and ‘meaningful homework
assignments exist only for a few disorders’.

5. 336 L. Fehm and N. Kazantzis
Copyright © 2004 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 11, 332–343 (2004)
questionnaires to a box positioned on the registra-
tion counter.
RESULTS
Use of Homework Assignments
Frequency of Homework Use
All practitioners in the present sample reported
using homework assignments for at least some
portion of their patients, and the vast majority
reported the regular use of homework. Overall,
37% of the sample reported the use of homework
for every patient, 26% reported use for two-thirds
of all patients, 13% reported use for half of all
patients, and 23% for a quarter of all patients.
During therapy itself, a sizeable proportion (13.4%)
reported using homework assignments in ‘every
therapy session’, and ‘in every second session’
(39%). Similarly, over half (62%) of the practition-
ers in the present sample reported using
homework assignments within the first five
therapy sessions, with 13% indicating that they
assigned homework during the first therapy
session.
As expected, there were consistent and statisti-
cally significant differences in the frequency of
homework use between cognitive–behavioral
and psychoanalytic practitioners. Cognitive–
behavioral practitioners reported a greater use of
homework, as measured by proportion of patients
c2
(4, N = 125) = 59.31, p < 0.001, but observed dif-
ferences did not achieve significance in chi-square
tests when homework use was measured by pro-
portion of sessions or use in first five sessions (see
Table 1). Those practitioners working in university
settings also described using more homework than
those working in other settings c2
(4, N = 126) =
11.75, p < 0.05, but contrary to expectation, other
observed differences between work settings did
not achieve statistical significance.
Types of Homework Assignments
Homework activities that involved ‘behavioral
experiments’ (86% of respondents) were only
slightly more popular than ‘self-monitoring’ and
‘cognitive restructuring’ (75% of respondents each)
and ‘applying new skills or techniques’ (71% of
respondents) for the sample overall. Again, cogni-
tive–behavioral practitioners reported significantly
greater use of the various types of homework activ-
ity than their psychoanalytic counterparts. This
included behavioral experiments c2
(1, N = 126) =
14.09, p < 0.001, self-monitoring c2
(1, N = 126) =
4.28, p < 0.05, cognitive restructuring c2
(1, N = 126)
= 5.88, p < 0.05, and applying new skills or tech-
niques c2
(1, N = 126) = 32.90, p < 0.001. (When this
data was examined using standardized residuals to
interpret the size of the differences, it was notable
that only standardized residuals for behavioral
experiments and applying new skills or techniques
reached the conventional cut-off value; see Bühl &
Zöfel, 2000, p. 239.) The use of cognitive restruc-
turing was more common among those practition-
ers working outside of the university setting,
c2
(1, N = 129) = 6.89, p < 0.01, but all other types of
homework assignment were used to the same
degree (all p > 0.05).
Table 1. Use of homework assignments by theoretical orientation and work setting
Variable CBT Psychoanalytic University Other
n % n % n % n %
Proportion of patients
Every patient 47 52.2 2 5.7 18 62.1 28 28.9
75% of patients 28 31.1 4 11.4 6 20.7 24 24.7
50% of patients 10 11.1 6 17.1 2 6.9 16 16.5
25% of patients 5 5.6 22 62.9 3 10.3 28 28.9
Never 0 0 1 2.9 0 0 1 1.0
Proportion of sessions
Every session 15 16.9 1 3.0 7 25.0 10 10.4
Every second session 44 49.4 2 6.1 12 42.9 32 43.8
During the first five sessions
First session 17 20.5 1 0.0 8 27.6 8 8.0
First five sessions 49 59.0 12 40.0 16 55.2 46 46.0
Percentages represent proportions of valid data.

6. Attitudes and Use of Homework Assignments 337
Copyright © 2004 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 11, 332–343 (2004)
Review of Homework Assignments
The vast majority of therapists reviewed the
patient’s completion of the homework assignments
at the next therapy session. Overall, 43% of practi-
tioners indicated that they ‘always’ reviewed
homework at the next session, 53% ‘mostly’ and
4% ‘rarely’, whereas none indicated that they
‘hardly ever’ reviewed homework. Interestingly,
there were no significant differences in the rate of
‘always’ or ‘mostly’ reviewing homework at the
next session between cognitive–behavioral and
psychodynamic practitioners, or those working
in different work settings (remaining categories
were not included due to small cell sizes, and all
p > 0.05).
Problems in Using Homework Assignments
In the present sample, the most common
problem in using homework assignments in
therapy was that patients do not complete the
homework as assigned (91% of respondents). Half
of practitioners indicated the use of homework
assignments that were too difficult for patients
(50% of respondents), and about a third indicated
using homework assignments that were unclear to
patients, or not eventually useful for therapy (each
31% of respondents). Seventeen percent of the
present sample indicated that they had patients
who did not complete the homework at all.5
Attitudes Towards Homework Assignments
We were interested in characteristics of practition-
ers that might be associated with different attitudes
towards homework assignments. As homework
assignments have evolved primarily in the context
of theory and research on cognitive and behavioral
therapies, we predicted that those practitioners
with a CBT orientation, as well as those working
in university or research settings, would hold more
positive attitudes towards homework assignments.
We also predicted that clinical experience should
be related to attitudes, and that those who reported
less difficulty getting their patients to complete or
comply with homework assignments would have
more favorable attitudes than those whom experi-
ence was negative or neutral.
As a first step in examining the attitudes of our
sample we classified practitioners as more ‘highly
experienced’ if they reported 4000 hours or more,
and ‘less experienced’ if they reported 2000 hours
or less. (This definition was based on the classifi-
cation introduced during the establishment of
German psychotherapy law in 1999.) Since practi-
tioners were asked to endorse five specific cate-
gories regarding the types of difficulty experienced
in using homework assignments (i.e. ‘too difficult
for the patient’, ‘unclear to the patient’, ‘not bene-
ficial for therapy’, ‘patients do not complete the
homework as assigned’ and ‘patients do not com-
plete the homework at all’), those that reported
none or one were classified as experiencing ‘less
problems with compliance’ and those that reported
three or more were classified as experiencing ‘more
problems with compliance’. Practitioners that
reported ‘less’ and ‘more’ problems with compli-
ance (i.e. 24 and 27% of the sample, respectively)
were contrasted because we predicted that these
groups would have greater diversity in attitudes
towards homework assignments.6
Data screening precluded the use of analysis of
variance techniques in the present study. Since the
study was preliminary, we computed independent
samples t-tests for each hypothesized comparison
between practitioner subgroups, but relied on the
effect sizes (d) produced in each comparison that
reached statistical significance at conventional
levels as the primary basis for interpretation and
discussion. (See discussion in Cohen, 1988, on
utility of interpreting magnitude of effect rather
than exclusive reliance on significance tests.)
Effects of Homework on Treatment Outcome
We first surveyed practitioners’ attitudes about
the effects of using homework assignments on
treatment outcome. Overall, the sample tended to
disagree with the assertion that there is a lack of
empirical support for homework (M = 1.82, SD =
1.16) and that practitioners can only be successful
if they use homework (M = 1.96, SD = 1.21). Con-
versely, practitioners agreed with the assertions
that homework is indispensable for change (M =
2.39, SD = 1.29), enhances therapy outcomes (M =
2.23, SD = 1.18) and facilitates behavior change
(M = 3.08, SD = 1.08), but at the same time did not
consider homework to be necessary for every
patient (M = 2.66, SD = 1.34).
5
There were no significant differences between cognitive–
behavioral and psychoanalytic practitioners in the problems
in using homework assignments, all p > 0.05.
6
Only a small proportion (6%) of the sample reported no dif-
ficulties with homework compliance, 17% reported one
problem, 49% reported two different problems, 14%
reported three problems, 4% reported four problems and 9%
reported five different problems.

7. 338 L. Fehm and N. Kazantzis
Copyright © 2004 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 11, 332–343 (2004)
Table 2 presents means, standard deviations and
significance tests on attitudes items for different
theoretical orientations (i.e. cognitive–behavioral
and psychoanalytic) and work setting (i.e. univer-
sity and other work settings) practitioner sub-
groups. Table 3 presents the date for practitioners
with differing levels of experience and problems
with homework compliance. As hypothesized,
there were consistent differences between cogni-
tive–behavioral and psychoanalytic practitioners’
attitudes regarding homework’s effects on treat-
ment outcome. (Because of the sample size
involved and the multiple tests in this exploratory
study, we chose to calculate effect size (d) in
the description of each attitude comparison.) As
shown in Table 2, psychoanalytic practitioners
were significantly more likely to agree with the
assertion that there is a lack of empirical support
for homework (d = -0.82) and assignments are not
necessary for every patient (d = -1.21), whereas
their cognitive–behavioral colleagues were signifi-
cantly more likely to agree with the assertions that
homework is indispensable (d = 1.01), enhances
outcomes (d = 1.08), is related to practitioners’
success (d = 0.85) and facilitates behavior change (d
= 1.05). Similarly, those practitioners employed in
the university setting considered homework to
be indispensable (d = 0.55), related to therapists’
success (d = 0.53) and necessary for behavior
change. Consistent with the comparison by theo-
retical orientation, those working in other settings
were more likely to agree with the notion that
homework assignments are not necessary for every
patient (d = -0.61). However, there were no signif-
icant differences in attitudes regarding homework
effects on treatment outcome by experience in
clinical practice (all p > 0.05), and those experienc-
ing more problems with compliance only differed
from those experiencing less problems in consid-
ering homework indispensable for therapy (d =
-0.49).
Process of Integrating Homework Assignments
into Therapy
We also surveyed practitioners’ attitudes regard-
ing the process of integrating homework assign-
ments into therapy. As Table 2 shows, there
were significant differences between cognitive–
behavioral and psychoanalytic practitioners once
again. Cognitive–behavioral therapists rated
greater agreement with the suggestion that thera-
pists and clients should design homework together
(d = 0.42), and that therapists should take some of
the responsibility to motivate patients (d = 0.79).
Conversely, psychoanalytic practitioners consid-
ered the process as requiring more creativity than
cognitive–behavioral practitioners in this sample
(d = -0.44). Practitioners working in university set-
tings only differed from those in other settings
with regards to therapist responsibility to motivat-
ing patients (d = 0.50). Table 3 shows that more
experienced practitioners only had significantly
different opinions about the degree of creativity
required in designing homework than their less
experienced colleagues (d = -0.47). Interestingly,
the perceived degree of therapist responsibility for
motivating patients was significantly higher
among those experiencing more difficulties with
patient compliance (d = -0.50).
Patients’ Homework Compliance
Finally, we surveyed practitioners’ attitudes
regarding patient compliance with homework
assignments. Specifically, we asked practitioners
whether they believed that all patients rejected
homework assignments, and for their general
belief about patient compliance with homework.
There was only one substantive difference between
practitioner subgroups, where psychoanalytic
practitioners rated greater agreement with the
belief that patients reject all homework assign-
ments than their cognitive–behavioral colleagues
(d = -0.49).
DISCUSSION
There are several important limitations to the
present study that should be acknowledged. First,
the sample size of 140 was not as large as we would
have liked. The sample size clearly limits the rep-
resentativeness of the sample, and it is also possi-
ble that interest in homework assignments or other
factors biased the sample. Given this possible lim-
itation, the diversity in use and attitudes towards
homework assignments is encouraging. Second,
the present study was a self-report survey of use
and attitudes towards homework assignments,
and did not measure the actual use of homework
in clinical practice. While attitudes may be impor-
tant in determining the extent and manner with
which homework assignments are integrated into
therapy, the evaluation of actual therapist adher-
ence and competence in delivering treatment will
ultimately determine the mechanism by which
homework produces its effects in therapy. Third,
the questionnaire used in the present study was a
preliminary measure of therapist attitudes towards

8. Attitudes
and
Use
of
Homework
Assignments
339
Copyright
©
2004
John
Wiley
&
Sons,
Ltd.
Clin.
Psychol.
Psychother.
11,
332–343
(2004)
Table 2. Attitudes towards homework assignments by theoretical orientation and work setting
Intem CBTa
Psychoanalyticb
t df Universityc
Otherd
t df
M SD M SD M SD M SD
Effects of homework on treatment outcome
1. There is a lack of empirical support 1.52 1.19 2.42 1.00 -3.97*** 120 1.93 0.96 1.74 1.19 -0.84 50.9
regarding the positive effects of
homework in therapy
2. Homework assignments are 2.78 1.16 1.62 1.14 5.13*** 125 2.93 1.13 2.26 1.28 -2.54* 127
indispensable, the most important
changes occur outside the therapy room
3. Homework assignments always 2.64 0.91 1.51 1.17 5.24*** 54.8 2.38 1.12 2.17 1.20 -0.84 127
enhance therapy outcomes
4. Therapists can only be successful if 2.22 1.09 1.25 1.20 4.38*** 123 2.41 0.98 1.82 1.22 -2.42* 126
they give directive and suggestions for
change
5. Homework assignments are not 2.20 1.32 3.54 0.84 6.86*** 103.4 2.07 1.22 2.84 1.29 -2.86** 127
necessary for every patient
6. Behavior changes have to be exercised 3.44 0.85 2.41 1.09 5.18*** 54.8 3.52 0.78 2.94 1.11 -2.62* 127
repeatedly, homework assignments are
essential for this
Process of integrating homework into therapy
7. The term ‘homework’ is deterring/ 2.01 1.38 2.44 1.50 -1.55 124 2.31 1.31 2.13 1.44 -0.60 126
discouraging
8. The therapist should make a note of 2.56 1.22 2.14 1.62 1.39 51.5 2.17 1.23 2.52 1.42 1.18 126
the assignment
9. Therapists and patients should always 2.91 1.15 2.41 1.24 2.21* 125 2.66 1.04 2.80 1.25 0.57 127
design assignments together
10. The therapist is responsible for 3.23 0.86 2.43 1.14 3.84*** 53.6 3.28 0.70 2.86 1.12 -2.42* 73.27
motivating the patient to complete
homework assignments
11. Much creativity is required from the 2.74 1.00 3.14 0.79 -2.12* 125 2.55 0.95 2.91 1.03 1.68 127
therapist for designing meaningful,
individualized assignments
Patients’ homework compliance
12. The majority of patients reject all 0.84 0.90 1.22 0.79 -2.19* 125 0.86 0.83 1.03 0.90 0.90 127
homework assignments
13. Patient compliance is very poor 1.39 0.73 1.47 0.94 -0.45 53.01 1.41 0.63 1.49 0.86 0.47 126
CBT = cognitive–behavioral therapy.
*p < 0.05; **p < 0.01; ***p < 0.001.
a
n = 90.
b
n = 37.
c
n = 29.
d
n = 100.

9. 340
L.
Fehm
and
N.
Kazantzis
Copyright
©
2004
John
Wiley
&
Sons,
Ltd.
Clin.
Psychol.
Psychother.
11,
332–343
(2004)
Table 3. Attitudes towards homework assignments by experience and problems with compliance
Item Psychotherapy experience t df Problems with compliance t df
Lessa
Highlyb
Lessc
Mored
M SD M SD M SD M SD
Effects of homework on treatment outcome
1. There is a lack of empirical support 1.81 1.18 2.07 1.15 -1.15 110 1.68 1.33 1.86 1.10 -0.62 65
regarding the positive effects of homework
in therapy
2. Homework assignments are indispensable, 2.51 1.30 2.26 1.29 1.02 114 2.15 1.33 2.74 1.06 -2.07* 69
the most important changes occur outside
the therapy room
3. Homework assignments always enhance 2.13 1.20 2.32 1.19 -0.85 113 2.15 1.18 2.43 1.24 -0.97 68
therapy outcomes
4. Therapists can only be successful if they 1.85 1.08 2.02 1.42 -0.70 110.9 1.82 1.24 2.03 1.26 -0.70 68
give directive and suggestions for change
5. Homework assignments are not necessary 2.58 1.34 2.75 1.34 0.70 114 2.79 1.41 2.58 1.46 -0.61 69
for every patient
6. Behavior changes have to be exercised 3.13 1.00 3.08 1.14 0.23 114 2.79 1.08 3.21 1.04 -1.67 69
repeatedly, homework assignments are
essential for this
Process of integrating homework into therapy
7. The term ‘homework’ is deterring/ 2.24 1.47 2.13 1.47 0.38 113 2.19 1.40 2.00 1.39 0.56 68
discouraging
8. The therapist should make a note of the 2.38 1.35 2.52 1.37 -0.56 114 2.31 1.47 2.68 1.44 -1.07 68
assignment
9. Therapists and patients should always 2.80 1.15 2.79 1.21 0.06 114 2.67 1.24 3.03 1.17 -1.25 69
design assignments together
10. The therapist is responsible for motivating 2.93 1.12 3.10 0.96 -0.89 114 2.76 1.06 3.26 0.95 -2.12* 69
the patient to complete homework
assignments
11. Much creativity is required from the 2.65 0.97 3.10 0.93 -2.53* 114 2.73 0.98 2.97 1.03 -1.03 69
therapist for designing meaningful,
individualized assignments
Patients’ homework compliance
12. The majority of patents reject all homework 1.00 0.94 0.89 0.84 0.69 114 1.00 0.75 0.97 0.97 0.13 69
assignments
13. Patient compliance is very poor 1.51 0.79 1.29 0.81 1.47 112 1.22 0.83 1.51 0.84 -1.46 67
Less experienced = 2000 hours or less. Highly experienced = 4000 hours or more. Less problems with compliance = one or less. More problems with compliance = three or more.
*p < 0.05; **p < 0.01; ***p < 0.001.
a
n = 55.
b
n = 61.
c
n = 33.
d
n = 38.

10. Attitudes and Use of Homework Assignments 341
Copyright © 2004 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 11, 332–343 (2004)
homework assignments, and coupled with the
sample size it was not possible to subject the items
to exploratory factor analysis. Fourth, it should
be noted that in the year 1999, when we conducted
the study, the literature dealing with homework
assignments in German journals was far from
being abundant. In our search of published studies
of treatment process and outcome, we could only
identify three articles from 1989 onwards in
German language sources. While this reflects the
importance of the findings from the present study,
it is possible that the lack of research and discus-
sion regarding homework assignments in the
German literature further limits the external valid-
ity of the data. Finally, even though homework
assignments may represent a core and essential
process in psychotherapy, they are only one aspect
of the process by which patients generalize skills
to the everyday situations in which their problems
actually occur. These limitations should be noted
when considering the implications of the findings
below.
The results of the present study suggest that
practicing psychologists differ substantially in the
extent to which they use homework in therapy
(Hypotheses 1 and 2). Approximately 37%
reported using homework with all patients, and
approximately 23% used homework for less than
half their patients. Although psychoanalytic prac-
titioners reported a lower overall frequency and
diversity in using different types of homework
assignment as compared with cognitive–behav-
ioral practitioners, the majority used homework
with at least some patients. In addition, practition-
ers of different theoretical approaches did not
differ in the regularity with which they reviewed
homework assignments (Hypothesis 3). Taken
together, these findings provide preliminary
support for the assumption (Badgio et al., 1999;
Kazantzis & Ronan, in press; Stricker, in press) that
homework assignments represent a common
process to these therapy approaches, and extend
prior research (Kazantzis & Deane, 1999; Kemmler
et al., 1992).
There were two findings that suggested practi-
tioners’ attitude towards homework assignments
may be formed principally through reading
research findings and discussion with colleagues
rather from direct clinical experience. First, while
all of the practitioners in our sample reported the
use of homework assignments, approximately 29%
reported that they ‘somewhat’ or ‘completely’
agreed with assertions that there is sufficient
empirical support for homework, and approxi-
mately 50% considered homework to enhance
therapy outcomes. Second, there were large differ-
ences in attitudes to ‘homework assignments
effects on treatment outcome’ between those prac-
ticing in the university setting and those practicing
elsewhere in seeing homework as indispensable,
related to therapist success and necessary for
behavior change. These findings suggest that clar-
ifying the existing empirical support for home-
work assignments will be essential for future
collegial discussions regarding the utility of home-
work in psychotherapy.
The present findings indicate that practicing psy-
chologists have a range of attitudes regarding the
way in which homework assignments should
be integrated into the process of psychotherapy.
Those endorsing a cognitive–behavioral theoretical
orientation saw the collaboration between the
patient and therapist as more important for design-
ing homework, and the therapist as being actively
responsible for encouraging (or motivating) pa-
tients to complete homework assignments. On the
other hand, those endorsing a psychoanalytic the-
oretical orientation considered the process of
homework administration as one that requires a
great deal of creativity. Although preliminary,
these findings provided partial support for our
prediction that theoretical orientation would be
related to attitudes towards homework assign-
ments (Hypothesis 4).
While the results of the present study suggest
that there is diversity in the theoretical basis under-
pinning the rationale and application of homework
assignments in clinical practice, there were also dif-
ferences as a function of work setting and clinical
experience. Degree of responsibility for motivating
patients to complete homework was also higher
among those working in university settings, and
those experiencing more differences with home-
work compliance. Additionally, more experienced
practitioners also rated the degree of creativity
required as more important for the use of home-
work assignments. These results highlight the
problems in assuming uniformity in practitioners’
attitudes regarding homework assignments, and
the way in which empirically supported processes
of psychotherapy are practiced in clinical settings
(i.e. partial support for Hypotheses 5 and 6).
The present study has provided some prelimi-
nary empirical data on practicing psychologists’
attitudes towards therapeutic homework assign-
ments. We conclude by suggesting some possible
avenues for future research. In the first instance,
there is a need for a more extensive survey of prac-

11. 342 L. Fehm and N. Kazantzis
Copyright © 2004 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 11, 332–343 (2004)
ticing psychologists’ attitudes towards the use
of homework assignments in psychotherapy. It
would be helpful to have a more extensive quanti-
tative survey that spans the broader range of pos-
sible attitudes surrounding the issues of perceived
homework effects on the outcome and process of
psychotherapy.
Despite the ongoing research being conducted on
the effects and correlates of homework compliance,
there are no current empirically supported models
or guidelines for using homework assignments in
practice. While prominent practitioner-researchers
have provided practitioner guidance on using
homework in psychotherapy, there has been rela-
tively little theory development in the research on
homework assignments. Behaviorally focused
models stemming from the medication compliance
literature have appeared (Shelton & Levy, 1981b),
and there has been some extension of this thinking
to the features of the patient presentation and spe-
cific homework activity that may determine utility
(Detweiler & Whisman, 1999), but further theoret-
ical work is required (see Kazantzis, Deane, Ronan,
& L’Abate, in press). If the results of the present
study can be replicated and extended, they would
suggest some inclusion of the therapist’s attitudes
and beliefs about the process of using homework
in therapy as part of a conceptual model for using
homework assignments in practice.
ACKNOWLEDGEMENTS
Preparation of this article was supported in part by
Massey University Research Award PR56786.1207
MURF to Nikolaos Kazantzis. The authors
acknowledge Robbie Busch for the German to
English translation of a preliminary version of this
manuscript.
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