Clinical Psychology and Psychotherapy Clin. Psychol. Psychother. 23, 260–271 (2016) Published online 27 April 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/cpp.1953

Redefining Outcome Measurement: A Model for Brief Psychotherapy Everett McGuinty,1,2* John Nelson,3 Alain Carlson,4 Eric Crowther,3 Dina Bednar5 and Mirisse Foroughe6,7 1

Faculty of Education, University of Western Ontario, London, Ontario, Canada Hands TheFamilyHelpNetwork.ca, North Bay, Ontario, Canada 3 North Bay, Ontario, Canada 4 Toronto, Ontario, Canada 5 Child and Adolescent Services, Hamilton, Ontario, Canada 6 Kindercare Pediatrics, Toronto, Ontario, Canada 7 The Hospital for Sick Children, Toronto, Ontario, Canada 2

Context: The zeitgeist for short-term psychotherapy efficacy has fundamentally shifted away from evidence-based practices to include evidence-informed practices, resulting in an equally important paradigm shift in outcome measurement designed to reflect change in this short-term modality. Objective: The present article delineates a short-term psychotherapy structure which defines four fundamental stages that all brief therapies may have in common, and are represented through Cognitive Behavioral Therapy, Solution-Focused Brief Therapy, Narrative Therapy, and Emotion-Focused Therapy. Method: These four theoretical approaches were analyzed via a selected literature review through comparing and contrasting specific and common tasks as they relate to the process of psychotherapy and change. Once commonalities were identified within session, they were categorized or grouped into themes or general stages of change within the parameters of a four to six session model of short-term therapy. Commonalities in therapeutic stages of change may more accurately and uniformly measure outcome in short-term work, unlike the symptom-specific psychometric instruments of longer-term psychotherapy. Results: A systematic framework for evaluating the client and clinician adherence to 20 specific tasks for these four short-term therapies is presented through the newly proposed, Brief Task Acquisition Scale (BTAS). It is further proposed that the client–clinicians’ adherence to these tasks will track and ultimately increase treatment integrity. Conclusion: Thus, when the client–clinician relationship tracks and evaluates the three pillars of (1) stage/process change, (2) task acquisition, and (3) treatment integrity, the culmination of these efforts presents a new way of more sensitively measuring outcome in short-term psychotherapy. Data collection is suggested as a first step to empirically evaluate the testable hypotheses suggested within this current model. Copyright © 2015 John Wiley & Sons, Ltd. Key Practitioner Message: • The clinician practitioner will note that the proposed Brief Services model removes the subjectivity of client satisfaction as a reliable outcome measure, and relies upon client and therapist adherence to specific tasks and stages of change within and across short-term psychotherapy. • The clinical significance of the BTAS for the practitioner is three fold. The psychometric instrument (1) tracks stage or process change, (2) guides task acquisition, and (3) incorporates greater treatment integrity unlike other outcome measures. • The BTAS present a new way of conceptualizing change in short-term psychotherapy regardless of modality or presenting issue, making it a more flexible and usable instrument for the clinician. • The BTAS may measure outcome more sensitively and accurately, thus offering the client, therapist and client-therapist more information regarding change at each stage and at the end of short-term psychotherapy. Keywords: outcome, short-term psychotherapy, measurement, process, therapeutic change *Correspondence to: Everett McGuinty, Hands HelpNetwork.ca, North Bay, Ontario, Canada E-mail address: [email protected]

Copyright © 2015 John Wiley & Sons, Ltd.

TheFamily-

Many people are reportedly not receiving the mental health care they need (Merikangas et al., 2011). This is supported by a multitude of factors contributing to this

Redefining Outcome Measurement growing problem; limited mental health resources and early withdrawal from services are both considered to be among the most prominent (Barrett et al., 2008; Kakuma et al., 2011). Recognition of such factors has led to growing interest in short-term psychotherapies, with a particular emphasis on remedying this complex problem through maximizing symptomatic change, or outcome, in shorter and shorter time periods. Kazdin (2007) noted that in spite of enormous progress in psychotherapy research, an evidence-based explanation for ‘how or why’ interventions produce change (mechanisms and moderators through which treatment interventions operate) remains elusive. Change process research continues to evolve as researchers investigate various aspects of what constitutes psychotherapy and the therapeutic relationship. Four streams of evaluative research have existed (Elliott, 2010) to present, including quantitative process-outcome, qualitative helpful factors, and micro-analytic sequential processes, and the significance-of-events approach. The last method represents a task analysis and comprehensive process analysis. Meta-concepts have been considered (Renninger, 2013) as essential to client change including collaborative goalsetting, stages of change and motivation, as well as experiential avoidance and exposure. Theories of emotional change (Greenberg, 2012), attention to the variability of alliance and outcome correlation (Lorenzo-Luaces, DeRubeis, & Webb, 2014), and therapist interventions (Cromer, 2013) all have been investigated as change agents. Progress monitoring tools have also been developed (Overington & Ionita, 2012) to monitor change throughout the therapeutic process. Most recently, a task model, reflecting three important clinical processes in interpersonal psychotherapy, was delineated (Kivlighan, 2014) including: focusing on the here and now, making impact disclosures, and creating corrective emotional experiences. Despite the widespread use of short-term therapies, from a variety of therapeutic approaches, there are a limited number of evaluations of whether shorter-term therapies can produce similar change, or effect size, as measured through outcome as compared with longerterm therapies. In sampling a range from a short-term framework, the authors have included a very brief descriptive review of four short-term therapy approaches that are established, to varying degrees, and reflect their unique histories in both the long-term and short-term modalities including: Cognitive–Behavioral Therapy, Solution-Focused Therapy, Narrative Therapy, and Emotion-Focused Therapy. These four different psychotherapies purport to address the spectrum of presenting issues for equally diverse clinical populations. They are all long-term and short-term models, though the latter applications will be considered for this exploratory article. For the purposes of this paper, short-term psychotherapy will be defined as treatments of as approximately four Copyright © 2015 John Wiley & Sons, Ltd.

261 to six sessions in length that primarily address a single goal or mild-to-moderate presenting issue, though secondary goals or concerns are often present. A secondary peripheral issue or concern may be relationally addressed; however, it would need to be directly related and connected to the focus of the primary presenting issue. Single session consultations, quick access sessions, and walk-in clinic sessions are considered a separate treatment modality on the psychotherapy spectrum. Their aims and focuses are often different from clinical issues that may require repeated meetings up to six sessions. These brief service modalities serve various internally and externally structural purposes, such as managing a crisis, problem solving, waitlist management, information sharing, triaging and referring to community resources, providing as gatekeeper to other internal agency services, and many other related and important functions. Nevertheless, they remain outside of the scope of this outcome measurement discussion. Our thesis is that all brief therapies share common elements, or therapeutic tasks. The purposes of this paper are to (1) propose a common and unifying structure representing the four short-term psychotherapies presented within, and (2) suggest a new paradigm of measuring change across this very unifying structure, regardless of presenting issue, clinical population, and perhaps even theoretical orientation. Four stages of change are presented that define the structure of short-term psychotherapy including: (1) define and explore the problem; (2) begin to shift the problem; (3) change the problem; and (4) maintain the shift and change. These specific stages are operationally defined through 20 descriptive and measurable constructs or tasks; and, for the first time capture session-by-session change with implications for the direction of short-term psychotherapy. We also suggest that the resulting new method of measuring effective outcome is suggested within short-term psychotherapy, which is both more sensitive to, and predictive of, lasting and measurable change. Unlike symptom-focused psychometric measures, the proposed Brief Task Acquisition Scale (BTAS) systematically measures the client–clinician adherence to task-specific goals set out for each of the four stages of psychotherapy. It is suggested that following this process of change more accurately reflects the therapeutic work in the short term. Furthermore, it represents a new and more effective language of outcome measurement, tracking therapeutic change, which conversely, very limited symptom-focused measurements cannot, as they capture pre and post measurements in symptom reduction. Because the BTAS is not symptom focused, but rather ‘process focused,’ it is hypothesized that it may be used with all psychotherapeutic approaches and all presenting issues, though this review and instrument were derived from four therapies. Within and across short-term therapy Clin. Psychol. Psychother. 23, 260–271 (2016)

E. F. McGuinty et al.

262 change is measured by the client and clinician, maximizing therapeutic change and possibly becoming the best predictor of longitudinal and lasting change for the client.

COMMONALITIES IN SHORT-TERM THERAPIES Short-term psychotherapy continues to mature from its infancy in development in establishing a niche to expanding its breadth of applicability. Solution-Focused Therapy and Narrative Therapy, in particular, have flourished internationally for their adaptability and resiliency in single session therapy, walk-in clinic settings, and short-term psychotherapy. Emotion-Focused Therapy focusing primarily on couples work, with the recent inclusion of family therapy through EFFT. Cognitive Behavioral Therapy has largely remained within the long-term realm with manualized treatment interventions becoming iconic for moderate to severe presenting issues. This is not to say that the latter approach has not been modified to successfully include short-term clinical work, as is often the case, especially from an Integrated Eclectic posture. Clinical models, however, are only as good as the desired mental health change the client and client–clinician relationship aspire. With varying theoretical models, the process of change can take many forms and immeasurable ways for the client and clinician to navigate both the therapeutic process and its mirrored image: change itself. Added to this are the complexities of other such factors as the client, the clinician, and the client–clinician relationship around endless interrelated and interdependent variables (preferences, competencies, personalities, resources, styles, dynamics, resiliencies, and the like). Given such rich diversity in theory, clinical pragmatics, and assumptions, a common skeletal infrastructure may exist between all short-term psychotherapies transcending their very differences. If such an underlying commonage exists within this ‘family of therapies,’ then the field of short-term psychotherapy would look more the same than different. Short-term psychotherapy would be comprised of approximately four to six sessions, each lasting 1 h in length regardless of the diversity of presenting issues: internalizing behavior versus externalizing behavior; individually focused versus family focused; and the like. A structure of therapeutic change within session (session-by-session) and across sessions (cumulative change throughout all brief psychotherapy sessions) would inform all therapies, clients, clinicians, and the client–clinician relationship of staying on course, much like a compass is instrumental in navigating uncharted territory. Such intentional posturing around the change process with psychotherapy structure and direct implications with outcome measurement are suggested within this article. Copyright © 2015 John Wiley & Sons, Ltd.

OUTCOME MEASUREMENT Evidence-based practices and evidence-informed practices attempt to speak to some form or degree in the collection and evaluation of evidence from a philosophical standpoint at minimum. A brief overview of what evidence-based has meant from a modern perspective is presented. The rubrics of evidence-based treatment are contextualized, or benchmarked, within the culture of long-term psychotherapy as short-term work was almost nonexistent early in its development. In turning to the science of describing what constitutes evidence-based parameters, it is worthy to note that evidence-supported interventions use mathematical estimates of risk of benefit and harm from research on population samples to inform clinical-decision making in the diagnosis, investigation, and/or management of clients (Greenhalgh, 2010). The National Health and Medical Research Council of Australia (1999) have presented ‘evidence-based’ criteria upon three broad dimensions that are useful to consider: the strength of evidence, the size of evidence, and the relevance of the evidence. The strength of the evidence is designed to inform the clinician on ‘how sure’ they can be that the treatment in question is significantly different than no treatment (or alternate comparison group). The size of evidence is often thought of with regards to metaanalysis, and can be interpreted in the context of outcome studies, as the amount the average client is expected to change. Finally, the relevance of the evidence for the client must be taken into consideration by the clinician. The easiest way to do this is matching the inclusion and exclusion criteria to the intended client population. Short-term psychotherapy is in its beginning stages of gathering outcome evidence, especially when compared with longer-term psychotherapies; even the measurement tools with which it experiments in collecting evidence are new, such as ‘scaling’ change in Solution-Focused Therapy and ‘client satisfaction surveys’ in Narrative Therapy. If the main focus of long-term psychotherapy is to maximize symptom reduction, then does it necessary follow that short-term therapy should accomplish the exact same results—proportionally? If the advantage of the former is to take pre/post measurements after lengthy periods of time, then the primary advantage of short-term psychotherapy (for the client, clinician, and client–clinician relationship) might be in its potential for incremental and more exact measurement. Incremental measurement, after each and every session, may serve a secondary purpose in guiding the course of short-term psychotherapy, an ‘integrity check’. Using multi-informant data collection, the client–clinician team can determine whether they are progressing toward the agreed upon change (1) within session, and (2) after each and every session. Such information may afford corrections, redirections, and affirmations in the process and experience of change in psychotherapy; and subsequently Clin. Psychol. Psychother. 23, 260–271 (2016)

Redefining Outcome Measurement each has an impact upon measurable change (which the pre/post outcome measurement design cannot sensitively and accurately capture because of its very structure). Careful attention and mindfulness to keeping psychotherapy on track and focused in each and every session will enhance greater change, and its opposite if not correctly redirected. Affirming the process, and change itself, may impact upon the client as they evaluate change with the clinician (and possibly others) at the end of each session and psychotherapy itself. The composition and structure of a five-session model versus a 20-session model are more different than they are similar. The goals, or tasks, embedded in the process for each and every session are mutually structured to achieve and guide the client toward greater mental health. The process for each of the five sessions in short-term psychotherapy does not equal the corresponding stages of change for 20 sessions, respectively, in long-term psychotherapy. Such reductionism is at the very base of the symptomology rubric, which the authors fundamentally reject. Even the composition and structure between therapy schools (for example, Cognitive Behavioral Therapy, Solution-Focused Therapy, Narrative Therapy, and Emotion-Focused Therapy) will greatly vary when the timeframe is expanded beyond short-term psychotherapy. Change is not uniform, constant, or linear, and the inherent assumptions in using longer-term instruments in shorter time frames are questionable, yet common practice within the short-term psychotherapy field. When the psychotherapy timeframe is purposefully collapsed to four to six sessions, each therapy school must restructure itself and adapt to address a very similar process regardless of presenting issue. Structural themes emerge, regardless of theoretical orientation, although each school defines itself as unique within the field. Fewer sessions may reduce the variability between short-term psychotherapies, uniting them to structurally address the core processes or stages of change. Again, this pruning of time strips theoretical orientations to their very skeletal core and what emerges is a unifying process of change. If similarity and simplicity in therapeutic structure exist, and if the process of change is relatively uniform, then designing an outcome measure for short-term psychotherapy might prove to be useful and yet unique. Such an outcome tool would represent a meaningful philosophical departure from existing outcome measurement, and introduce a paradigm shift toward new and long awaited methods of measurement in short-term psychotherapy.

SEEKING A STRUCTURE OF SHORT-TERM PSYCHOTHERAPY Measuring incremental change throughout the course of short-term psychotherapy more sensitively reflects the Copyright © 2015 John Wiley & Sons, Ltd.

263 client experience and client–clinician experiences of change within psychotherapy. The authors contend that asking a client to measure change after 20 sessions (or 20+ weeks after therapy has begun) could be burdensome and less valid, and introduce extraneous variables that confound the post-outcome measurement. Assessing and reassessing change, negotiating change, reflecting upon change, and measuring change in the present moment offer a feedback loop of information into the relationship system, with the potential for bringing greater outcome accuracy and change itself. What is accomplished in the first session (problem definition and exploration for example) is not the same as in the last session (maintaining the change previously attained). Within session change also means measuring micro-change where the hour is broken into sections, even moments that facilitate process research. This exploratory article now turns to four different schools of psychotherapy that view and address issues from wide treatment spectrums, not to mention how change is theorized and contextualized within a specific set of processes. What follows is an analysis of what the authors suggest is a grouping of specific and common tasks, when taken together, represent stages of structural change. Four identifiable stages of change emerge as a connective structure. It is further suggested that each of the four stages contain five specific tasks that the client and clinician must navigate to implement change within session, across psychotherapy, and longitudinally. The implications for identifying these 20 shared tasks would be to structure the process of psychotherapy. The authors believe that tracking and the acquisition of the 20 tasks and the four general stages of change would offer a comprehensive and sensitive outcome measurement of short-term psychotherapy. A brief review of these four therapies is represented below from a four to six session model. The contributing authors have 10–25 years of clinical experience, lecturing, and training in these four short-term psychotherapy models. Their inclusion within this review was selective, and the emerging ideas within the design of the BTAS evolved out of a synergistic analysis. The treatment models are now presented paying attention to common stages of change, unifying and underlying structural similarities, and specific tasks that these brief psychotherapies may share.

COGNITIVE BEHAVIORAL THERAPY Cognitive behavioral therapy (CBT) is a collaborative and structured short-term, problem-solving therapy that has been shown to be effective in the treatment of many mental health disorders across different age groups, cultures, and settings (Beck, 2005; Butler, Chapman, Forman, & Beck, 2006). This approach focuses on changing a client’s Clin. Psychol. Psychother. 23, 260–271 (2016)

264 maladaptive thought patterns and behaviors, and is based on the assumption that the way we perceive events or situations influences how we feel and act. The overall goal of CBT is to teach clients the skills that they can use on their own in the future. Hayes, Hope, and Hayes (2007) suggested that mapping the change process involved in cognitive behavior psychotherapy will result in (1) further refinement of treatment procedures, (2) a clearer picture of the process of recovery, treatment dropout and poor response, and relapse, and (3) the development of new therapeutic techniques that more specifically activate the process by which change occurs. Research and clinical work has progressed to the point that practitioners can apply the principles of CBT to multi-problem clients in a much shorter time period than 10–14 weeks when limited insession hours are available (Padesky & Greenburger, 1995). In terms of defining and assessing the problem, CBT theorists (Alford & Beck, 1997) and clinicians (Beck, 2011) stress the importance of (1) developing and maintaining a strong therapeutic relationship with the client from the first point of contact, and (2) developing realistic goals for short-term work. While clients are instructed about the cognitive model, and educated about their problems, it is essential (particularly with issues such as depression), to work on reducing their distress (Beck, 2011; Feeley, DeRubeis, & Gelfand, 1999). Clinicians also set in motion a process of socializing clients into therapy by instructing them about homework and its importance, by setting an agenda, by eliciting their reactions to the therapeutic process and by making sure that they understand what the clinician is thinking and proposing. Shifting the problem involves weaving together a number of interrelated tasks such as developing a case formulation or conceptualization while teaching clients about skill building and problem solving specific issues (Persons, 2008). Action plans or homework based on the conceptualization are developed with the clients in order to make changes in their problematic thinking and/or behavior. Homework from the previous week is reviewed at the beginning of each session. Clients are also often referred to one of the many treatment manuals available on the market in order to help remind them that the skills they develop to solve one problem can also be applied to other issues (Padesky & Greenburger, 1995). Change is a direct result of the client being actively involved in treatment during each session and in-between sessions. The key phrase in terms of cementing behavioral change is to ‘respond differently to’ the three levels of thoughts. Clients then recognize that ‘getting better’ involves making small changes ‘one step at a time’ in how they think or what they do. As was noted in the introduction, the client is introduced to the idea of termination at the beginning of therapy. Maintaining the change (or relapse prevention as it is called in the CBT literature) is facilitated by a number of techniques, such as: attributing Copyright © 2015 John Wiley & Sons, Ltd.

E. F. McGuinty et al. progress to the client; emphasizing that the tools they have used can be applied to other issues; preparing them for setbacks after therapy is over; responding to concerns about therapy ending; reviewing what was learned in therapy; and discussing a self-therapy plan (Beck, 2011).

SOLUTION-FOCUSED BRIEF THERAPY Solution-Focused Brief Therapy (SFBT) was developed by Steve de Shazer (Berg, 1994; de Shazer, 1984; de Shazer, 1985), Insoo Kim Berg, and their colleagues and clients at the Brief Therapy Centre in Milwaukee, USA. The approach grew out of the brief therapy work of the Mental Research Institute in Palo Alto, California, USA, and Dr. Milton Erickson’s Brief Therapy and trance work (de Shazer, 1984; de Shazer, 1985; de Shazer, 1988; O’Hanlon, Hudson, & Weiner-Davis, 1989).This approach is strength-based, future-focused, goal directed, and a short-term approach that helps clients resolve present problems by building on their existing resources and previously applied effective solutions. Fundamental assumptions are that clients are the experts of their lives and have the resources to deal with their problems (Trepper, Dolan, McCollum, & Nelson, 2006), and no problem happens all the time. It is assumed that for every problem there is an exception either already existing or possible. A problem therefore is conceptualized in solution-focused therapy as problem/exception (de Shazer, 1991). The first stage of SFBT work involves three main objectives: inquiring about pre-session change (de Shazer & Dolan, 2007), discovering the strengths and resources of the client; and defining the ‘problem’ and what the client wants different as a result of coming to therapy (solution/attainable goal). Main interventions include looking for previous solutions, looking for exceptions, questions instead of directives or interpretations, present and future-focused questions, assigning tasks, and compliments. Specific interventions consist of the ‘Miracle Question’, ‘Solution-Focused Goals’, and ‘Scaling’. The second stage involves identifying and amplifying exceptions (De Castro & Guterman, 2008), where the therapy focuses on what is already working and what has worked in the past. Exceptions are amplified and viewed as helpful to clients in identifying differences between the times that they have the problem and times when they do not. If clients are unable to identify exceptions, then clinicians might encourage clients to consider small differences (Walter & Peller, 1993). Clients who are unable to identify any exceptions may be asked to suppose or imagine potential exceptions in the future as in the ‘Crystal Ball’ or ‘Miracle Question’ technique. In this stage the focus is on shifting the problem. The third stage focuses on creating change and the client ‘doing something different’ (Walter & Peller, 1993). In this Clin. Psychol. Psychother. 23, 260–271 (2016)

Redefining Outcome Measurement stage the clinician assigns tasks aimed at clarifying and building on the problem, goal, exceptions, or potential exceptions identified in the previous stages. These tasks or experiments are usually based on something the client is already doing (exceptions), thinking, or feeling. Tasks may include noticing what is working, to keep doing what they are doing, and/or to do something different. Alternatively, the client may design their own tasks or experiments. Evaluating the effectiveness of these tasks also takes place in this stage. The fourth and final stage involves maintaining the change and re-evaluating the problem and goal. Here the client and clinician consider the extent to which the exceptions and tasks resulted in the attainment of the goal (de Shazer, 1984; Molnar & de Shazer, 1987; Walter & Peller, 1993). Discussions on how to maintain the progress ‘What do you need to keep doing to stay on track?’ and how the client would know he/she were getting off track, ‘What would be the first sign that you were getting off track?’ are explored and amplified. The client is consulted about ending therapy, which is carefully processed. These four stages of highlighting strengths and setting goals; identifying and amplifying exceptions; creating change from the client “doing something different”; and dialogue about maintaining the changes make SolutionFocused Therapy an effective brief therapy. SFBT is one of the most commonly practiced brief therapies among its group, and continues to evaluate itself for effectiveness within the short-term framework.

NARRATIVE THERAPY Narrative theory (White, 1988/1989; White & Epston, 1990) primarily rests upon a co-creative conversational journal in which the client–clinician relationship begins to deconstruct the problem and problem saturated story. The problem, often initially viewed as internal and part of identity, is externalized, objectified, and contextualized as separate and understood within the context of culture, history, social-economic, social context, and the like. The client–clinician relationship draws to attention an array of supportive life stories, or narratives, thickening the description (the unearthing and plotting of unique outcomes) and supporting the subordinate storyline development. These processes are nonlinear and often circular as the clinician takes a directive and poststructuralist stance (Payne, 2006) shaping and re-authoring identity with the aim of improved mental health and personal agency. Before defining and assessing the influences of the problem on the client and client relationships, the client– clinician may explore strengths and resources embedded within rich stories past, present, and even future that are useful to put up against the problem in launching the first of four stages. Deconstructing the problem begins by Copyright © 2015 John Wiley & Sons, Ltd.

265 naming it, exploring its impact upon the areas of the client’s life as an ongoing assessment process. Problems are identified, objectified, personified, and externalized, first through the use of language, and often later, in cliniciangenerated metaphor(s). A resulting person-and-problem relationship is described and viewed as separate entities, impacting upon the client’s view of self, others, and life. The client–clinician relationship begins to explore exceptions or unique outcomes that subvert the existing problem saturated story, through the medium of narratives, and also support the client’s taking a position against the problem. The client organizes experience into preferred stories which assist in developing alternative knowledge of self, and also support taking a position against the problem which may include the counselor being an ‘audience’ to the client sharing a story of when they had influence over the externalized problem. Significantly shifting the narrative begins much in the same way as the problem was deconstructed in the first stage; however, unique outcomes (or exceptions and initiatives) are named and described, then explored, and evaluated. Metaphors are often the vehicle of this shifting phase as Freeman, Epston, and Lobovits (1997) indicated the journey of separating problem from identity, accomplished through several metaphors of externalization. White (2007) developed 28 categories of common metaphors clinicians could use in shifting the ‘problem-narrative’ and ‘unique outcome-narrative’. Narratives that go-against or defy the problem are identified and described. Their effects are explored in relations of self, others, and life (as well as hopes, wishes, wants, dreams, etc.). Consolidating the change through a narrative-metaphor dynamic is the main focus of this third stage. After a brief review, the clients’ continued experience of events and actions supports and thickens a richly preferred narrative that has shifted and changed identity conclusions (who the client is and has become in relation to the problem). The effects of these preferred narratives and newly found knowledge are further dovetailed into the developing storyline. The client reevaluates these preferred developments and continues to experience events and actions, reflecting upon the past and present and bringing the future to the present. The use of metaphors in therapy (Battino, 2005; Kopp, 1995) is often emphasized, and what is externalized often shifts and changes over time as an ongoing process (Russell & Carey, 2004). McGuinty, Armstrong, and Carriere (2013) further develop, question, and explore the use and effectiveness of metaphors in Narrative Therapy. In efforts to both promote and maintain the client change, the clinician further thickens the storyline development by the continued plotting and integrating of unique outcomes—the counter narratives, which often occur between sessions and in session. Attention to narrative (and the meta-narrative story, supporting the changing identity) and complex metaphors are expanded through Clin. Psychol. Psychother. 23, 260–271 (2016)

266 the witnessing of important others, and others who are no longer with the client through re-membering; and meaning making continues to support the hopes, wishes, wants, beliefs, and the like, of the client. The use of therapeutic letters, consultants, and the general evaluation of new meaning promotes the continuing development and meaning of identity. The clinician reminds the client that this forward–backward process continues throughout lifetime, as stories counter to the effects of the problem emerge through life experience. Narrative Therapy embodies a process of conversation and questioning including the four phases of naming/describing, exploring the effects/impacts, evaluating, and justifying. And these phases are purposefully repeated for both the deconstruction of the problem and the subordinate storyline development. In total, eight categories of questioning represent the process of this intervention. Inherent in this psychotherapeutic approach is that identity is shaped by our life stories (or narratives) past, present, and future that others, the community, our cultures, and perhaps most importantly, our selves tell our self. Knowledge, power, and meaning are constructed from a social worldview (Freedman & Combs, 1996).

EMOTION-FOCUSED THERAPY Emotion-Focused Therapy is a humanistic–integrative, research-derived method that emphasizes the primacy of human emotion in psychological functioning and therapeutic change. Within the EFT approach, change is regarded as transformational, rather than learning to cope with distressing emotions. While EFT adopts an integrative frame including cognition, behavior, motivation, and relational functioning, there is a sustained focus on a person’s emotions as the primary pathway to change. In service of this, the EFT therapist works directly with the client’s emotion. A distinct emphasis on experiential engagement and felt-emotions is considered to be the primary catalyst to the process of change in therapy; a person needs to feel their feelings in order to change them, or to arrive at a place before they can leave it (Greenberg, 2012). While an assumption of EFT is that emotions are fundamentally adaptive in human survival and well-being, emotional processes can become problematic for people as a result of past traumas or even ongoing misattunement between the person’s emotional needs and what is available in their environment, leading to a pattern of emotion avoidance. This avoidance results in increasing pain and distress, as well as interfering with the individual’s ability to identify their needs and goals. With earlier roots in humanistic, gestalt, and existential therapies (Frankl, 1959; May, 1977; Perls, Hefferline, & Goodman, 1951; Rogers, 1957; Yalom, 1980) as well as family systems theory (Bowen, 1966; Pascual-Leone, Copyright © 2015 John Wiley & Sons, Ltd.

E. F. McGuinty et al. 1987), EFT later drew on advances in cognitive neuroscience and emotion research (Damasio, 1999; Frijda, 1986; Izard, 2002; Tamietto & de Gelder, 2010). Within the context of this range of influences, EFT theory and approach were derived primarily through several years of research into the process of therapeutic change, and were in part a response to the overemphasis on cognition and behavior in Western psychotherapy (Greenberg, 2002). The process of emotional change is captured in six sequential stages in EFT, through which clients are helped to identify, experience, accept, explore, make meaning of, transform, and flexibly manage their emotions. These stages are divided into a first, middle, and final stage of treatment. The first phase of treatment in EFT involves therapeutic bonding and developing of the client’s emotional awareness. From the first meeting, the therapist will reframe the client’s narrative in order to bring to awareness to the underlying emotions and direct the client’s attention to their inner experience in the moment, as well as in moments of distress. In addition to, and in some ways necessary for, this awareness of their emotional states, the client is helped to access the lived experienced of the painful emotion through exercises such as focusing on the bodily sensations or ‘felt-sense’ associated with the emotion, empty-chair and two-chair work, and overcoming selfcritical interruptions that automatically arise to block the person’s attempts at feeling and expressing their feelings. In this initial phase, the overarching task is to arrive at the core maladaptive emotion and vivify that experience. Through an interplay of following and leading the client, though always checking to see if any ‘leads’ do not fit with the client’s own experience, the therapist weaves through the narrative along with the client in pursuit of the emotional experience at the core of it. While the emotionfocused therapist does explore client history and listen to the narrative of the problem, their reflections back to the client will encourage an inward focus, on the client’s lived emotional experience, including physical sensations and feeling states. If the client has difficulty identifying emotional experiences, the therapist can use emphatic conjecture and suggest the emotion, based on the client’s presentation and following the client’s ‘pain compass’. The therapist ending their response to the client with a reference to emotion increases the likelihood that the client will be directed to emotional experience in their next response; the therapist leads the client to attend to the emotion. However, the therapist’s ‘leading’ is decidedly open-ended and tentative, allowing the client to correct the wording, or even the core emotion that was felt, if it does not fit with their experience. Once the core maladaptive emotion or painful feeling is identified and accepted by the client, the therapist can move to the middle phase of emotion coaching: evoking and exploring the emotion. This process of arriving at an emotional response can be best facilitated experientially, Clin. Psychol. Psychother. 23, 260–271 (2016)

Redefining Outcome Measurement such as through having the client assume the role of the part of him that elicits the emotional response. For example, the therapist can use two-chair dialogue to have the client take the role of a self-critic to show contempt or scare himself by enacting the self-dialogue and internal process that elicits the response of shame or fear in the self. A similar process can be used regardless of what the core emotion may be. The therapist could then move the client back to the ‘self’ or experiencing chair, and speak from the self’s perspective to describe the emotion elicited by the critic. The chair work clarifies the different ‘parts’ of the self, including previously disallowed parts, with eventual goal of reintegrating these parts for a greater sense of acceptance and harmony. In accessing the actual emotional experience that has been associated with a presenting problem, the client opens up a window of opportunity for transformation, which characterizes the third phase of EFT. With the lived emotional experience now ‘open’, the client’s response to the maladaptive process can generate new emotions, such as empowered anger. This new emotional experience can be strengthened over time, leading to a natural action tendency associated with the new emotion (e.g. assertive limit-setting with empowered anger) which is woven into the client’s narrative or meaning-making system. The revision of the narrative is a final step, made possible by directly accessing and ‘undoing’ the maladaptive emotion with a new adaptive emotion (Greenberg & Angus, 2004; Tugade & Fredrickson, 2007). The therapist utilizes empathic attunement throughout the process of emotion coaching. Attunement moves beyond expressed empathy, to moment-by-moment tracking of the client’s experience, and responding to markers of emotional significance, keeping the process of emotional change in mind. While the therapist facilitates the process, what is transformative in EFT is the client experiencing and symbolizing their distressing feeling (fear, sadness, shame, etc.) and accessing an alternative adaptive emotional response (self-soothing, empowered anger, etc.), which can be used as a self-healing resource (Greenberg, 2011). This intensely experiential process of emotional transformation is often difficult to appreciate until one has experienced it first hand, either as client or therapist. New EFT practitioners often comment that training in the approach is highly demanding and requires a level of emotional attunement and intimacy with the client’s experience that can be anxiety-provoking (Timulak, 2014). Certainly, EFT practitioners can often find that in the process of guiding their clients through highly painful emotions, there is a need to process their own emotional blocks, or unfinished business. While this can be highly threatening, it is also an opportunity for ongoing growth and self-awareness—indeed, the majority of EFT practitioners would likely agree that this learning is a lifelong process. As well, EFT posits that the only way out of pain Copyright © 2015 John Wiley & Sons, Ltd.

267 is through it, and a therapist acknowledging and healing personal hurts will, in the end, transform them into a more effective therapist for their client.

MEASURING CHANGE THROUGH TASK ACQUISITIONS Upon a closer examination of these four representative therapies, the authors propose that not only do general stages of change exist, but also common therapeutic tasks emerge and are represented differently though theory and intervention within each session and throughout short-term therapy. Embedded in theoretical orientation and language, client and clinician move through common stages, and when the stages are compared across therapies, a pattern of specific and shared tasks link all short-term therapies. All tasks are certainly not shared, and some therapies omit certain tasks; however, upon analysis it is suggested that five basic tasks exist across therapies for each of the four common stages. The authors reviewed the above summaries of the change process described for each type of short term therapy, and summarized the key stages or therapeutic tasks described. While many differences exist between these four therapies (and an Integrated Eclectic approach potentially synthesizing aspects of these therapies) a set of common tasks emerged when the change process was reviewed by the authors and therapeutic tasks common to all approaches were identified. When the therapeutic task sequence was arranged, the tasks were reviewed to ensure they had face validity with psychotherapies listed in this article. Some therapy schools are uncomfortable with using the words ‘task’ or ‘stage’, and so these words could be replaced with others that captures the same theoretical concept. The first of 20 tasks is to ‘name and mutually understand the problem’. Each clinician from the four theoretical camps accomplishes this goal or ‘task’ very differently (see the above four therapies for examples). Tasks are often embedded and implied within techniques, layers of questioning, assignments between sessions, exercises in session, and so deeply apart of a philosophical stance that they become hidden within that therapy culture. The suggested list of tasks (see Brief Task Acquisition Scale) is set forth as individual tasks standing on their own. When grouped together, as is the case of the first five tasks, they represent a stage in the psychotherapeutic process. And when all 20 are taken together, they represent the therapeutic process of therapy itself. Each task is scored on a five-point Likert scale for the client and clinician. The task list represents the core of treatment in short-term work and can provide a structure to therapy itself. It is a guiding therapeutic tool and evaluation outcome instrument for within session change and at the Clin. Psychol. Psychother. 23, 260–271 (2016)

E. F. McGuinty et al.

268 Table 1.

Brief Task Acquisition Scale (BTAS) Very much

Rate task completion:

4

Moderately

3

2

Not at all 1 Client

0 Clinician

Stage 1: Defining and assessing the problem 1. Name the problem and develop a common understanding 2. Identify influences of problem within areas of life 3. Explore the severity, or size, of the problem 4. Evaluate preferences, commitments, and motivations for change 5. Assess strengths and resources as they relate to problem Stage 2: Shifting the problem 6. Brief review and assess readiness/motivation to begin change 7. Explore experiences of emotion, beliefs, and actions as they relate to the problem 8. Further develop the change that is already happening 9. Develop positive action oriented plan and signs that it occurs in other aspects of life 10. Encourage smaller, manageable steps to maximize likelihood of early success base upon skills and abilities Stage 3: Changing the problem 11. Review understanding of problem and progress since last session 12. Pay attention to and reflect what is working and do more of that 13. Assign tasks that clarify and build on plan, goals, and exceptions 14. Make small adjustments based on what the client is already doing, thinking, and feeling 15. Identify expected change between sessions, new change areas now possible, and start to build in methods of independently supporting this change after therapy ends Stage 4: Generalizing and maintaining the change 16. Develop plan to maintain the change, while including the support from others to sustain this 17. Expand the change to include other areas where it needs to occur 18. Anticipate and plan for obstacles to continued success, and when getting off track, through exploring 19. Evaluate to what extent the tasks, stages, and change resulted in the goal for therapy 20. Discuss the ending of the process and the possible need for more service

end of therapy. Transparently capturing within session change offers the client, clinician, and therapeutic relationship important information in the present—unlike other symptom-reduction psychometric instruments (Table 1). From this within session perspective, the client and clinician would separately rate their perception of to what degree the tasks were successfully addressed for each of the five tasks, taking a minute or two to complete either within the session or near the end of each session. This evaluative system would include the client score (and in the case of children, a parent, teacher, guardian, and other score) and the assigned clinician score. The clinician also assesses the tasks, and a quick and raw client and clinician score would capture the session through adding the scores. Differences and commonalities in scores (task

Copyright © 2015 John Wiley & Sons, Ltd.

specific, stage specific, therapy specific) would offer valuable, incremental, and time-specific information to the client and clinician, and relationship. The 20 tasks represent the newly proposed BTAS instrument, designed to guide and capture measurable and more specific change in brief psychotherapy. It is a tool just as much for the client and it is for the clinician, focusing on incremental change and not symptom reduction. It is further suggested that when the 20 tasks are successfully navigated that it will more accurately measure what happened in psychotherapy compared with a before and after symptom-specific outcome measure. Individual item scores, subscale scores, total scores for the client, and total scores for the clinician will all give valuable feedback in session, after session, and after therapy has concluded. Client and clinician interpretation of the task(s) and

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Redefining Outcome Measurement process as a whole could also serve to guide and address treatment issues. Transparent discussions about tasks that represent process and change are vital. Expectations around outcome measurement in shortterm therapy need to more accurately reflect the work being done on such a short timeline, as should expectation about the accuracy and type of information such measures should provide. The BTAS attempts to redefine the expectations, structure, and outcome of short-term therapies by seeking common ground within the field, when therapies look to differentiate and define them as unique. Symptomspecific psychometric instruments offer valuable information in longer-term therapy, and certainly have their place in the field as they capture change regardless of theoretical orientation as well.

DISCUSSION An interactive instrument that offered direct feedback into the system could enhance outcomes with different presenting problems because five measures (or psychotherapeutic tasks) would be negotiated and evaluated within each and every session by both the client and clinician. They would both be cognizant of the within and across therapy score(s) and change process as well or total score for each stage of change. Continued co-evaluation around specific short-term tasks in psychotherapy would make the process of change more transparent and demystify therapy itself for the client, potentially improving motivation, collaboration and empowerment. This new method of outcome measurement would also be the most practice based instrument of its kind, continually drawing a response from the ‘client as expert’ on their interpretation of success/change in short-term psychotherapy task-by-task. It would afford evaluative reflection keeping the process of change center stage. Added to this, the clinician would also measure outcome with the client present and not behind closed doors through statistical analysis long after the client has ended therapy. Genuine and direct clinician input would impact upon the client– clinician relationship along the lines of mutual trust, greater communication, shared goal development and attainment, and other relational factors. This may also provide a way to develop clinical practice through the clinician’s own evaluation of areas where they consistently excel and require professional development (searching for consistent patterns in high and low scores).The potential is for the clinician to receive clarification and direction from the client, and gain a further understanding of the client’s knowledge and evaluation of the therapeutic process in a much more formalized and routine manner. This could inform the clinician on their own skill-development through self-reflection, as they are rated by client and themselves Copyright © 2015 John Wiley & Sons, Ltd.

269 over the 20 psychotherapeutic tasks. The BTAS might also offer greater accountability to private and government stakeholders, if it indeed measures what it purports to in the short-term.

LIMITATIONS A potential limitation may arise with multi-informant sources, where the presenting problem is represented and contextualized through several people, such as in a family unit. It could prove difficult and time consuming to obtain independent scores from several family members, agreeing on the level of change within an overall stage and/or specific task. On the other hand, it could prove fruitful where discrepancies exist. The clinician would need to weigh the advantages and disadvantages, and perhaps use the BTAS for primarily stage change. And second, the BTAS was developed through only four types of short-term therapies, and thus the tasks may not be representative of other short-term therapies in measuring change. Furthermore, relying on self-reporting on tasks and stages may measure conscious reflection, and not truly capture or accurately measure the underlying issue of being unconsciously resistant to change. Other limitations relate to the nature of session-bysession measurement. These limitations could undermine the effectiveness of this tool, and will need to be closely monitored and clinically evaluated. One such example could include the issue of client compliance, or the wish to please the therapist. The client may want to demonstrate that they are changing and being successful to please the therapist, though this may not be true. Another example is the issue of clinician anxiety in regard to identifying their areas for professional development. Clinicians may feel anxious around certain tasks or stages that they identify as areas for improvement, and this could impact upon their own scores. Thus these two issues could confound the scoring and results of the task rating scale. Difference in scores between the client and the clinician can have an emotional impact upon their relationship as well, and in turn, impact the BTAS scale itself.

CLINICAL EVALUATION Clinical evaluation of the BTAS is planned around both the tasks and the weighting of the measurement for each task and the stage(s) scores as well. First, clinician feedback will be important in further developing this new tool both individually and through focus groups. The tasks need to be further evaluated through a large sample of clinicians from various schools of psychotherapy. Second, clinicians will use the tool with a sample size of clients to inform the clinicians’ understanding of the tool’s Clin. Psychol. Psychother. 23, 260–271 (2016)

270 impact on therapy. Third, the authors are interested in evaluating the impact of having a measurement tool within each and every session from the client, clinician, and therapeutic relationship perspectives, the latter offering information on how well therapy is or is not progressing. Evaluation efforts are planned through the adult clinical population at university student counseling centers, where BTAS scores might account for a large and significant amount of variance in long-term symptom outcome measures. Fourth, the authors will also be looking at psychometric information development, in particular the reliability (inter-rater and test-retest) and predictive validity (symptoms at endpoint) of this newly proposed instrument, and concurrent and discriminant validity with the Working Alliance Inventory, Feedback Informed Therapy measures, and other symptoms measures.

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