The introduction of homework brings along important changes to the therapeutic relationship. Cognitivie-behavioral-oriented therapists often believe that direct exploration of the therapeutic relationship is the exclusive domain of the psychodynamic approach.1 Although exploring the therapeutic relationship is not central in cognitive therapy, there are often dysfunctional automatic thoughts and related feelings that arise in the interactions between therapist and client. Exploring and modifying these automatic thoughts can be crucial to the success of therapy.2-3 When introducing homework to the psychotherapeutic process, the therapist should be vigilant to the reaction of the patient and discuss any negative emotions and related automatic thoughts elicited.
When introducing therapy homework, psychotherapists should consider how the patient may react. They should pay attention to what automatic thoughts the patient may have, in particular in relation to what doing psychotherapy means about them and what it means about the role of the therapist:
Many patients have a hard time doing written assignments in between sessions because of what this might imply about themselves.3 Patients may interpret doing homework as proof that there is something really wrong with them. It is easier to accept having emotional problems during the one hour a week they meet with a therapist than to accept the role of a person that "needs to do homework daily."
Patients frequently expect their therapist to play a supportive role and contain their emotions, like a parent would.4 While for the therapist, therapy might be all about the cognitive model, for the patient it might be all about telling a painful story in a contained environment. Introducing homework in therapy could make the relationship seem like a teacher-student relationship. Patients could interpret the introduction of homework by their therapist as a parent telling a child "you have to kiss your own boo-boo." Having to do homework means the patient will have to take charge, at least in part, of containing their own emotions. This could be empowering, but it could also be perceived as rejection. It is important for the therapist to understand what are the interpersonal expectations of the individual patient and to make the homework appropriate to them. For instance, a first assignment could be a simple log of daily activities, mood charting or a combination of the two. This could be presented as a gathering of information for use by the therapist, rather than self-healing.
In addition to the perceived and expected roles of patient and therapist, two other factors that play an important part in the successful introduction of homework in therapy are:
Cognitive behavioral therapists should aim to establish an open and collaborative relationship.5 These characteristics are of particular importance when planning homework assignments. It is important to tailor the homework to the individual patient and decide as a team what assignments make sense. The therapist should consider the patient's level of motivation and cognitive skills. Giving out an assignment that is too hard could be discouraging; conversely, one that is too easy and/or meaningless could be perceived as childish.
It is easier to get the assignments right later on in the course of therapy. When the therapist knows the patient better it is easier to understand what assignments make sense to the individual patient. When the patient has learned more about the cognitive-behavioral model it is also easier for him/her to participate in the decision process to select meaningful assignments.5 In the early stages of therapy it is harder to make homework seem relevant. As therapy progresses, it is likely that clarifying cognitive distortions and identifying core beliefs will become an important part of the therapeutic process. At this point even patients that had never been compliant with homework before might become very motivated to start questioning their automatic thoughts on their own.