Q: How do I get clients to do homework assignments?
A: Please don't call them homework assignments. That evokes memories of tasks handed out in school, which often seemed like busywork. The best way to ensure clients' cooperation is to make the assignments relevant for them. Task assignments are designed to bring about changes in the presenting problem. We try to make sure they are relevant to clients by having a mutually agreed upon definition of the problem being addressed and then collaboratively designing tasks that relate to it. In fact, when the tasks derive from a collaborative relationship, they often don't feel like tasks at all.
There are several ways to design tasks collaboratively. We present multiple possibilities and suggestions and then try to anticipate clients' responses to potential tasks by telling stories about other clients who performed a task assignment similar to the one we think might help them. If clients shake their heads adamantly during such a story, we understand that this may not be the best task for them. Likewise, if clients are smiling or nodding, we get a sense we are probably on the right track.
Steffanie once saw a family who had been referred by their pediatrician because their 10-year-old son had been having escalating temper tantrums since his surgery for severe colitis. The family had never been to therapy, but they settled in quickly and readily discussed their son's colitis and temper tantrums. Steffanie reassured them about the likelihood of solving the problem and proceeded to give examples of tasks that had worked for other families. The father began to shift in his chair and sigh as
Steffanie spoke about these interventions. After observing this, Steffanie turned to the father and said, "I think I'm off target in some way. I notice you seem uncomfortable when I start to talk about things that might help."
The father said, "You're telling us things we can do to stop the tantrums. We thought that if we brought him here, you could work with him and stop the tantrums." Steffanie and the family talked about psychotherapy with kids and discussed the fact that Steffanie preferred to work by involving the family in making changes because they were really the experts on their kids and would be around when most of the tantrums occurred. Both parents seemed relieved and the mother confided that they felt responsible for missing the warning signs of their son's illness and were scared to "do anything wrong again." They had come to mistrust their judgment and think "the professionals know better." Newly empowered to take control of the situation, the family worked with Steffanie on setting clearer limits and developing other strategies for dealing with the tantrums.
Assignments have to be road tested. Do they work for the clients? Were there unpredicted glitches? For us this is the stuff of treatment—the feedback we receive from the assignment often determines the direction of the session. For instance, Bill told a couple having fights about money about another couple he had worked with who had committed to weekly budget "summits" in which they would make joint decisions about household expenditures. The couple agreed to do the task, but when they returned, they reported that it hadn't worked. The wife said, "He outtalks me every time and gets his way because he's better at arguing. He's like a lawyer and makes such a forceful and persuasive case. I don't represent my side well." Knowing that, Bill helped the couple hash out new ground rules for discussions so that they could both be heard and represented. This helped with the money discussions and with other areas of difficulty as well.
Another way to increase the likelihood of follow-through on tasks is to write the assignments down and then do a follow-up. We keep duplicate task forms handy so that we can give clients one copy and keep the other to refer to at the next session. This way, clients have something concrete in hand to hang on the refrigerator and review during the interval between sessions. It also makes us more likely to remember to follow up with clients in the next session, which communicates to the clients that the assignment wasn't just dreamed up to test their compliance.
When we first started to use task assignments, we didn't get as much cooperation as we do now. It is clear to us now that we were unsure whether our clients would follow through and that we sent them ambivalent messages about our expectations. These days, we assume clients will do the tasks and our language reflects this: "After you do this, I will want to follow up on how it went," rather than, "If you do this, let me know how it went." This simple effort of presupposing the client will comply can make a dramatic difference. On the other hand, if clients don't do the assignments between sessions, we don't automatically assume they are being resistant. We discuss the assignment and ask what happened. Often we discover the assignment was not clear enough, didn't fit or was just too much to take on during a particularly busy or otherwise overwhelming week.
When tasks are habitually not done, we use this analogy with clients: "I keep firing the starting pistol, but you haven't left the blocks yet. You say you want to reach the finish line (your goal of fighting less, feeling happier, getting a better job), but you're still at the starting position looking at me as if to say, 'Why aren't I at the finish line yet?' The task we discussed is the starting pistol. Actions get you off the blocks and to the finish line."
When clients say they just don't have time or doing the task isn't a priority, we sometimes talk to them about whether they are motivated to work on the problem now, and suggest they might want to return to therapy when they have the time and energy to focus on it. We have a bottom-line operating principle: the therapist should never be the most motivated person in the room.
This blog is excerpted from "The Dog Ate It," by Bill O'Hanlon. The full version is available in the May/June 1998 issue, Rethinking Crime and Punishment: What Do Therapists Have to Offer?
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