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
2
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

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 par-
adigm 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 funda-
mental stages that all brief therapies may have in common, and are represented through Cognitive Be-
havioral Therapy, Solution-Focused Brief Therapy, Narrative Therapy, and Emotion-Focused Therapy.
Method: These four theoretical approaches were analyzed via a selected literature review through com-
paring 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 ulti-
mately 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 collec-
tion is suggested as a first step to empirically evaluate the testable hypotheses suggested within this cur-
rent 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 TheFamily-

Many people are reportedly not receiving the mental
HelpNetwork.ca, North Bay, Ontario, Canada health care they need (Merikangas et al., 2011). This is
E-mail address: everettmcguinty@hotmail.com supported by a multitude of factors contributing to this

Copyright © 2015 John Wiley & Sons, Ltd.

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 explana-
tion 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 repre-
sents a task analysis and comprehensive process analysis.
Meta-concepts have been considered (Renninger, 2013)
as essential to client change including collaborative goal-
setting, stages of change and motivation, as well as experi-
ential 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 interper-
sonal psychotherapy, was delineated (Kivlighan, 2014) in-
cluding: 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 lim-
ited number of evaluations of whether shorter-term thera-
pies can produce similar change, or effect size, as
measured through outcome as compared with longer-
term therapies. In sampling a range from a short-term
framework, the authors have included a very brief de-
scriptive 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 psycho-
therapies 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 psychother-
apy 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 sec-
ondary 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 con-
nected to the focus of the primary presenting issue. Single
session consultations, quick access sessions, and walk-in
clinic sessions are considered a separate treatment modal-
ity on the psychotherapy spectrum. Their aims and fo-
cuses 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 ele-
ments, or therapeutic tasks. The purposes of this paper
are to (1) propose a common and unifying structure
representing the four short-term psychotherapies pre-
sented within, and (2) suggest a new paradigm of measur-
ing change across this very unifying structure, regardless
of presenting issue, clinical population, and perhaps even
theoretical orientation. Four stages of change are pre-
sented that define the structure of short-term psychother-
apy 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 mea-
surable constructs or tasks; and, for the first time capture
session-by-session change with implications for the direc-
tion of short-term psychotherapy.
We also suggest that the resulting new method of mea-
suring effective outcome is suggested within short-term
psychotherapy, which is both more sensitive to, and pre-
dictive of, lasting and measurable change. Unlike
symptom-focused psychometric measures, the proposed
Brief Task Acquisition Scale (BTAS) systematically mea-
sures 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 ac-
curately reflects the therapeutic work in the short term.
Furthermore, it represents a new and more effective lan-
guage of outcome measurement, tracking therapeutic
change, which conversely, very limited symptom-focused
measurements cannot, as they capture pre and post mea-
surements 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)
262
change is measured by the client and clinician, maximizing
therapeutic change and possibly becoming the best predic-
tor of longitudinal and lasting change for the client.
COMMONALITIES IN SHORT-TERM
THERAPIES
Short-term psychotherapy continues to mature from its in-
fancy in development in establishing a niche to expanding
its breadth of applicability. Solution-Focused Therapy and
Narrative Therapy, in particular, have flourished interna-
tionally for their adaptability and resiliency in single ses-
sion therapy, walk-in clinic settings, and short-term
psychotherapy. Emotion-Focused Therapy focusing pri-
marily 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, espe-
cially 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 clini-
cian, 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 pragmat-
ics, and assumptions, a common skeletal infrastructure
may exist between all short-term psychotherapies
transcending their very differences. If such an underly-
ing 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 di-
versity of presenting issues: internalizing behavior ver-
sus 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, cli-
ents, 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 psychother-
apy structure and direct implications with outcome
measurement are suggested within this article.
Copyright © 2015 John Wiley & Sons, Ltd.
E. F. McGuinty et al.
OUTCOME MEASUREMENT
Evidence-based practices and evidence-informed prac-
tices attempt to speak to some form or degree in the collec-
tion 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 meta-
analysis, 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 eas-
iest 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 gath-
ering 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 ther-
apy should accomplish the exact same results—proportion-
ally? 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, clini-
cian, 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 correc-
tions, redirections, and affirmations in the process and ex-
perience 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 psychother-
apy 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 psy-
chotherapy does not equal the corresponding stages of
change for 20 sessions, respectively, in long-term psycho-
therapy. 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 Ther-
apy, 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 inher-
ent 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 col-
lapsed to four to six sessions, each therapy school must re-
structure 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 psycho-
therapies, 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 sim-
ilarity 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 par-
adigm 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 af-
ter 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 pre-
viously attained). Within session change also means mea-
suring 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 im-
plications for identifying these 20 shared tasks would be
to structure the process of psychotherapy. The authors be-
lieve that tracking and the acquisition of the 20 tasks and
the four general stages of change would offer a compre-
hensive and sensitive outcome measurement of short-term
psychotherapy.
A brief review of these four therapies is represented be-
low from a four to six session model. The contributing au-
thors 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 sim-
ilarities, 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 situ-
ations 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) sug-
gested that mapping the change process involved in cogni-
tive behavior psychotherapy will result in (1) further
refinement of treatment procedures, (2) a clearer picture of
the process of recovery, treatment dropout and poor re-
sponse, and relapse, and (3) the development of new thera-
peutic 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 in-
session 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 main-
taining 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 prob-
lems, it is essential (particularly with issues such as de-
pression), 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 under-
stand what the clinician is thinking and proposing.
Shifting the problem involves weaving together a num-
ber of interrelated tasks such as developing a case formula-
tion or conceptualization while teaching clients about skill
building and problem solving specific issues (Persons,
2008). Action plans or homework based on the conceptual-
ization 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 be-
ginning of each session. Clients are also often referred to
one of the many treatment manuals available on the mar-
ket in order to help remind them that the skills they de-
velop to solve one problem can also be applied to other
issues (Padesky & Greenburger, 1995).
Change is a direct result of the client being actively in-
volved 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’ in-
volves making small changes ‘one step at a time’ in how
they think or what they do. As was noted in the introduc-
tion, the client is introduced to the idea of termination at
the beginning of therapy. Maintaining the change (or re-
lapse prevention as it is called in the CBT literature) is fa-
cilitated 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 Men-
tal 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 prob-
lems 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 objec-
tives: 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 (solu-
tion/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 compli-
ments. Specific interventions consist of the ‘Miracle Ques-
tion’, ‘Solution-Focused Goals’, and ‘Scaling’.
The second stage involves identifying and amplifying
exceptions (De Castro & Guterman, 2008), where the ther-
apy 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 cli-
nicians might encourage clients to consider small differ-
ences (Walter & Peller, 1993). Clients who are unable to
identify any exceptions may be asked to suppose or imag-
ine potential exceptions in the future as in the ‘Crystal
Ball’ or ‘Miracle Question’ technique. In this stage the fo-
cus 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 ex-
ceptions 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 ex-
periments. 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 ex-
ceptions 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 Solution-
Focused 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 de-
scription (the unearthing and plotting of unique outcomes)
and supporting the subordinate storyline development.
These processes are nonlinear and often circular as the cli-
nician 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 prob-
lem 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 cli-
ent’s life as an ongoing assessment process. Problems are
identified, objectified, personified, and externalized, first
through the use of language, and often later, in clinician-
generated 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 excep-
tions 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 prob-
lem. 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 initia-
tives) are named and described, then explored, and evalu-
ated. 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 ex-
plored 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 ac-
tions 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 ef-
fects of these preferred narratives and newly found knowl-
edge 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 effective-
ness of metaphors in Narrative Therapy.
In efforts to both promote and maintain the client
change, the clinician further thickens the storyline devel-
opment by the continued plotting and integrating of
unique outcomes—the counter narratives, which often oc-
cur 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 mean-
ing making continues to support the hopes, wishes,
wants, beliefs, and the like, of the client. The use of thera-
peutic 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 life-
time, 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, evalu-
ating, and justifying. And these phases are purposefully
repeated for both the deconstruction of the problem and
the subordinate storyline development. In total, eight cat-
egories of questioning represent the process of this inter-
vention. 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 thera-
peutic 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 rela-
tional 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 emo-
tion. 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 funda-
mentally adaptive in human survival and well-being, emo-
tional processes can become problematic for people as a
result of past traumas or even ongoing misattunement be-
tween 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 neurosci-
ence and emotion research (Damasio, 1999; Frijda, 1986;
Izard, 2002; Tamietto & de Gelder, 2010). Within the con-
text 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, expe-
rience, 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 aware-
ness. 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 mo-
ments of distress. In addition to, and in some ways neces-
sary 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 self-
critical 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 emo-
tional experience at the core of it. While the emotion-
focused 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 emo-
tional experiences, the therapist can use emphatic conjec-
ture 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 ref-
erence 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 exam-
ple, 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 even-
tual 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 ten-
dency 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 revi-
sion of the narrative is a final step, made possible by di-
rectly 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 be-
yond 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 emo-
tional 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 ex-
perience that can be anxiety-provoking (Timulak, 2014).
Certainly, EFT practitioners can often find that in the pro-
cess of guiding their clients through highly painful emo-
tions, 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 practi-
tioners 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 ther-
apies omit certain tasks; however, upon analysis it is sug-
gested 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 ther-
apy, and summarized the key stages or therapeutic tasks
described. While many differences exist between these
four therapies (and an Integrated Eclectic approach poten-
tially synthesizing aspects of these therapies) a set of com-
mon 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 the-
oretical concept. The first of 20 tasks is to ‘name and mu-
tually understand the problem’. Each clinician from the
four theoretical camps accomplishes this goal or ‘task’
very differently (see the above four therapies for exam-
ples). Tasks are often embedded and implied within tech-
niques, 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 psychotherapeu-
tic process. And when all 20 are taken together, they rep-
resent 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 ther-
apy 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)
268 E. F. McGuinty et al.

Table 1. Brief Task Acquisition Scale (BTAS)

Very much Moderately Not at all

Rate task completion: 4 3 2 1 0

Client 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 rela-
tionship important information in the present—unlike
other symptom-reduction psychometric instruments
(Table 1).
From this within session perspective, the client and cli-
nician 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
specific, stage specific, therapy specific) would offer valu-
able, incremental, and time-specific information to the cli-
ent and clinician, and relationship.
The 20 tasks represent the newly proposed BTAS instru-
ment, 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, focus-
ing on incremental change and not symptom reduction. It
is further suggested that when the 20 tasks are success-
fully 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

Copyright © 2015 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 23, 260–271 (2016)
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 short-
term therapy need to more accurately reflect the work be-
ing 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 expec-
tations, structure, and outcome of short-term therapies by
seeking common ground within the field, when therapies
look to differentiate and define them as unique. Symptom-
specific psychometric instruments offer valuable informa-
tion 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 pre-
senting problems because five measures (or psychothera-
peutic 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 motiva-
tion, collaboration and empowerment.
This new method of outcome measurement would also
be the most practice based instrument of its kind, continu-
ally drawing a response from the ‘client as expert’ on their
interpretation of success/change in short-term psycho-
therapy 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 at-
tainment, and other relational factors.
This may also provide a way to develop clinical prac-
tice 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 re-
ceive 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 govern-
ment 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 mem-
bers, 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 measur-
ing change. Furthermore, relying on self-reporting on
tasks and stages may measure conscious reflection, and
not truly capture or accurately measure the underlying is-
sue of being unconsciously resistant to change.
Other limitations relate to the nature of session-by-
session 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 feed-
back 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 cli-
nicians 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 offer-
ing 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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