Therapeutic Homework to Support Recovery From Severe Mental Illness

Therapeutic homework refers to activities that clients complete between their visits with mental health workers. The aim of such homework is to facilitate progress toward treatment goals. There is an increasing body of research indicating that homework completion is associated with improved outcomes of psychotherapy across a wide range of clinical disorders (such as depression and anxiety). However, there is limited research into the role of homework in mental health case management for people with severe mental illnesses such as schizophrenia. Many mental health service providers are actively involved in delivering specific client interventions such as skill development, activities to improve physical health, and the promotion of medication adherence. All of these, at least in theory, require practice in natural community environments for successful integration into the person's everyday life. Systematic homework implementation has a critical role in supporting people with serious mental illness to achieve their recovery goals.

The collaborative recovery model (CRM) is a case management approach to operationalize contemporary recovery principles—hope, meaning in life, and personal responsibility—in clinical practice. Our research team has been conducting a formal evaluation of the CRM, as part of the Australian Integrated Mental Health Initiative (AIMhi).

This evaluation has involved training hundreds of mental health workers from government and nongovernment mental health services across four Australian states. Systematic homework implementation is one of six core training components of the CRM. Within this model, collaboratively developed homework assignments are used to promote progress toward the person's recovery goals and encourage client self-management, responsibility, and skill development.

An early topic of the homework training is the suitability of the term "homework." For many clients (and case managers) the term feels negative because it is associated with unhappy school experiences or might seem overly paternalistic. We use the term because it is used in treatment manuals and the research domain. However, in practice we encourage clients and clinicians to use terms that they both find acceptable, such as "home exercises" or "home practice."

Homework training also emphasizes a systematic approach to homework administration that involves collaborating with the client to identify how often, in what length of time, where, and when the homework should be completed. In addition, a written record of the homework providing these details is required. Our research has shown that although over 90% of mental health workers say they use homework, in practice only 15% write down the details for clients as noted above. Written details can help address cognitive problems some people with psychosis experience, such as difficulties with memory or planning. A homework assignment pad is provided that includes prompts (where, when, how often, and so on) to structure an assignment, guide the worker and client, ensure the assignment is sufficiently behaviorally specific, and provide a written record. The pad is carbonized, enabling the client and case manager to retain a copy of the assigned homework for subsequent review. Research suggests that such written details are associated with better homework completion and more positive treatment outcomes than assignments without written reinforcement.

The training does not prescribe the types of homework assignment to be implemented. However, we direct workers toward examples of treatment manuals that include recommended assignments because these are evidence-based resources. Given the idiosyncratic needs and goals of individuals with serious mental illness, we emphasize principles of implementation and encourage workers and clients to collaboratively develop homework that can be linked to the person's own recovery goals. For example, a 24-year-old woman diagnosed as having schizophrenia was living in supported accommodation. To address her recovery goal of being more independent, one of the homework assignments she developed with her case manager involved visiting a real estate agent and viewing a potential apartment.

As part of the AIMhi trial, case managers were encouraged to implement homework on at least a fortnightly basis. In practice only around 50% of trained workers implemented any homework using written forms. Of those who used the homework forms, the frequency of assignment was much lower than suggested. Despite this result, our preliminary findings indicate a significant association between the number of written assignments and treatment outcomes, such that more frequent homework was associated with more positive outcomes on measures of symptom distress and psychological functioning. The major challenge is getting mental health workers to more consistently use systematic homework procedures to support their clients in progressing toward their recovery goals.