Student code ………………… Score ……………………...

COGNITIVE THERAPY SCALE - REVISED

(CTS-R)

I.-M. Blackburn, I.A. James, D.L. Milne &

F.K. Reichelt

Collaborators:
[Link], C. Baker, S.H. Standart & A. Claydon

Newcastle upon Tyne, UK - August 2000

THE REVISED COGNTIVE THERAPY SCALE AUGUST 2000

Scorer:……………………………………………. Date:………………………………………….

COGNITIVE THERAPY SCALE - REVISED (CTS-R)

The rating of the scale

The present seven point scale (i.e. a 0-6 Likert scale) extends from (0) where the therapist did not adhere to
that aspect of therapy (non-adherence) to (6) where there is adherence and very high skill. Thus the scale
assesses both adherence to therapy method and skill of the therapist. To aid with the rating of items of
the scale, an outline of the key features of each item is provided at the top of each section. A description
of the various rating criteria is given in the right hand margin - see example below in Figure 1. Further
details are provided in the accompanying manual.

The examples are intended to be used as useful guidelines only. They are not meant to be used as
prescriptive scoring criteria, rather providing both illustrative anchor points and guides.

Adjusting the scale in the presence of patient difficulties

The scale's dimensions were devised for patients assessed as being well/moderately suited for cognitive
therapy (Safran & Segal, 1990). As such, adjustments may need to be made when patient difficulties are
evident (e.g. excessive avoidance). Indeed, with problematic patients it is sometimes difficult to apply CT
methods successfully; that is, with desirable change. In such circumstances the rater needs to assess the
therapist's therapeutic skills in the application of the methods. Thus even though the therapist may be
unsuccessful at promoting change, credit should be given for demonstrations of appropriate skilful
therapy.

Safran, J.D. & Segal, Z.V. (1990) Interpersonal processes in cognitive therapy. New York, Basic Books.

Figure 1: Example of the scoring layout

Key features: this is an operationalised description of the item (see examples within the CTS-R).
Mark with an 'X' on the vertical line, using whole and half numbers, the level to which you think the
therapist has fulfilled the core function. The descriptive features on the right are designed to guide your
decision.

N.B. When rating, take into consideration the appropriateness of therapeutic interventions for stage of
therapy and perceived patient difficulty.

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THE REVISED COGNTIVE THERAPY SCALE AUGUST 2000

Competence level ________________Examples ______

0 absence of feature, or highly inappropriate performance

Incompetent
1 inappropriate performance, with major problems evident
Novice
2 evidence of competence, but numerous problems and lack of consistency
Advanced
beginner
3 competent, but some problems and/or inconsistencies
Competent
4 good features, but minor problems and/or inconsistencies

Proficient
5 very good features, minimal problems and/or inconsistencies

Expert 6 excellent performance, even in the face of patient difficulties

* The present scale has incorporated the Dreyfus system (Dreyfus, 1989) for denoting competence,
which is described fully in the manual. Please note that the 'top marks (i.e. near the 'expert' end of the
continuum) are reserved for those therapists demonstrating highly effective skills, particularly in the
face of difficulties (i.e. highly aggressive or avoidant patients; high levels of emotional discharge from
the patients; and various situational factors).

The `Key Features' describe the important features that need to be considered when scoring each
item. When rating the item, you must first identify whether some of the features are present. You
must then consider whether the therapist should be regarded as competent with the features. If the
therapist includes most of the key features and uses them appropriately (i.e. misses few relevant
opportunities to use them), the therapist should be rated very highly.

The `Examples' are only guidelines and should not be regarded as absolute rating criteria.

Scoring Distribution
It is important to remember that the scoring profile for this scale should approximate to a normal
distribution (i.e. mid-point 3), with relatively few therapists scoring at the extremes.

Dreyfus, H. L. (1989). The Dreyfus model of skill acquisition. In J. Burke (ed.) Competency based
education and training. London: Falmer Press.

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ITEM 1 - AGENDA SETTING & ADHERENCE

Key features: To address adequately topics that have been agreed and set in an appropriate way.
This involves the setting of discrete and realistic targets collaboratively.. The format for setting the
agenda may vary according to the stage of therapy - see manual.

Three features need to be considered when scoring this item:

(i) presence/absence of an agenda which is explicit, agreed and prioritised, and feasible in the
time available;
(ii) appropriateness of the contents of the agenda (to stage of therapy, current concerns etc.), a
standing item being a review of the homework set previously;
(iii) appropriate adherence to the agenda.

Mark with an 'X' on the vertical line, the level to which you think the therapist has fulfilled the core
function. The descriptive features on the right are designed to guide your decision.

NB: Agenda setting requires collaboration and credit for this should be given here, and here alone.
Collaboration occurring at any other phase of the session should be scored under Item 3
(Collaboration).

Competence Examples
level NB: Score according to features, not examples!

0 No agenda set, highly inappropriate agenda set, or agenda not adhered to.

1 Inappropriate agenda set (e.g. lack of focus, unrealistic, no account of

patient's presentation, homework not reviewed).

2 An attempt at an agenda made, but major difficulties evident (e.g. unilaterally set).
Poor adherence.

3 Appropriate agenda, which was set well, but some difficulties evident (e.g.
poor collaboration). Some adherence.

4 Appropriate agenda, minor difficulties evident (e.g. no prioritisation), but

appropriate features covered (e.g. review of homework). Moderate adherence.

5 Appropriate agenda set with discrete and prioritised targets - review at the
end. Agenda adhered to. Minimal problems.

6 Excellent agenda set, or highly effective agenda set in the face of difficulties.

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ITEM 2 - FEEDBACK

Key features: The patient's and therapist's understanding of key issues should be helped through the
use of two-way feedback: The two major forms of feeding back information are through general
summary and chunking of important units of information. The use of appropriate feedback helps both
the therapist to understand the patient's situation, and the patient to synthesise material enabling
him/her to gain major insight and make therapeutic shifts. It also helps to keep the patient focused.

Three features need to be considered when scoring this item:

(i) presence and frequency, or absence, of feedback. Feedback should be given/elicited

throughout the therapy - with major summaries both at the beginning (review of week) and end
(session summary), while topic reviews (i.e. chunking) should occur throughout the session;
(ii) appropriateness of the contents of the feedback;
(iii) manner of its delivery and elicitation (NB: can be written).

Competence Examples
level NB: Score according to features, not examples!

0 Absence of feedback or highly inappropriate feedback.

1 Minimal appropriate feedback (verbal and/or written).

2 Appropriate feedback, but not given frequently enough by therapist, with

insufficient attempts to elicit and give feedback, e.g. feedback too vague to
provide opportunities for understanding and change.

3 Appropriate feedback given and elicited frequently, although some difficulties

evident in terms of content or method of delivery.

4 Appropriate feedback given and elicited frequently, facilitating moderate

therapeutic gains. Minor problems evident (eg. inconsistent).

5 Highly appropriate feedback given and elicited regularly, facilitating shared

understanding and enabling significant therapeutic gains. Minimal problems.

6 Excellent use of feedback, or highly effective feedback given and elicited

regularly in the face of difficulties.

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ITEM 3 - COLLABORATION

Key features: The patient should be encouraged to be active in the session. There must be clear
evidence of productive teamwork, with the therapist skillfully encouraging the patient to participate
fully (e.g. through questioning techniques, shared problem solving and decision making) and take
responsibility. However, the therapist must not allow the patient to ramble in an unstructured way.

Three features need to be considered: the therapist style should encourage effective teamwork
through his/her use of:

(i) verbal skills (e.g. non-hectoring);

(ii) non-verbal skills (e.g. attention and use of joint activities);
(iii) sharing of written summaries.

NB: Questioning is a central feature with regard to this item, but questions designed to facilitate
reflections and self discovery should be scored under Item 9 (Guided Discovery).

Competence Examples
level NB: Score according to features, not examples!

0 Patient is actively prevented or discouraged from being collaborative.

1 The therapist is too controlling, dominating, or passive.

2 Some occasional attempt at collaboration, but didactic style or passivity of

therapist encourages passivity or other problems in the therapeutic
relationship.

Teamwork evident, but some problems with collaborative set (e.g. not
3 enough time allowed for the patient to reflect and participate actively).

Effective teamwork is evident, but not consistent. Minor problems evident.

4

Effective teamwork evident throughout most of the session, both in terms of

5 verbal content and use of written summaries. Minimal problems.

6 Excellent teamwork, or highly effective teamwork in the face of difficulties.

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ITEM 4 - PACING AND EFFICIENT USE OF TIME

Key features: The session should be well 'time managed' in relation to the agenda, with the session
flowing smoothly through discrete start, middle, and concluding phases. The work must be paced well
in relation to the patient's needs, and while important issues need to be followed, unproductive
digressions should be dealt with smoothly. The session should not go over time, without good reason.

Three features need to be considered:

(i) the degree to which the session flows smoothly through the discrete phases;
(ii) the appropriateness of the pacing throughout the session;
(iii) the degree of fit to the learning speed of the patient.

Competence Examples
level NB: Score according to features, not examples!

0 Poor time management leads either to an aimless or overly rigid session.

1 The session is too slow or too fast for the current needs and capacity of the
patient.

Reasonable pacing, but digression or repetitions from therapist and/or

2
patient lead to inefficient use of time; unbalanced allocation of time, over
time.

3 Good pacing evident some of the time, but diffuse at times. Some
problems evident.

4 Balanced allocation of time with discrete start, middle and concluding

phases evident. Minor problems evident.

5 Good time management skills evident, session running smoothly.

Therapist working effectively in controlling the flow within the session.
Minimal problems.

6 Excellent time management, or highly effective management evident in the

face of difficulties.

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ITEM 5 - INTERPERSONAL EFFECTIVENESS

Key features: The patient is put at ease by the therapist's verbal and non-verbal (e.g. listening skills)
behaviour. The patient should feel that the core conditions (i.e. warmth, genuineness, empathy and
understanding) are present. However, it is important to keep professional boundaries. In situations
where the therapist is extremely interpersonally effective, he/she is creative, insightful and
inspirational.

Three features need to be considered:

(i) empathy - the therapist is able to understand and enter the patient's feelings imaginatively and
uses this understanding to promote change;
(ii) genuineness - the therapist has established a trusting working relationship;
(iii) warmth - the patient seems to feel liked and accepted by the therapist.

Competence Examples
level NB: Score according to features, not examples!

0 Therapist's manner and interventions make the patient disengage and

become distrustful and/or hostile (absence of/or excessive i, ii, iii).

1 Difficulty in showing empathy, genuineness and warmth.

Therapist's style (e.g. intellectualisation) at times impedes his/her empathic

2 understanding of the patient's communications.

The therapist is able to understand explicit meanings of patient's

3
communications, resulting in some trust developing. Some evidence of
inconsistencies in sustaining relationship.

4 The therapist is able to understand the implicit, as well as the explicit

meanings of the patient's communications and demonstrates it in his/ her
manner. Minor problems evident (e.g. inconsistent).

5 The therapist demonstrates very good interpersonal effectiveness. Patient

appears confident that he/she is being understood, which facilitates self-
disclosure. Minimal problems.

Highly interpersonally effective, even in the face of difficulties.

6

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ITEM 6 — ELICITING OF APPROPRIATE EMOTIONAL EXPRESSION

Key features: The therapist facilitates the processing of appropriate levels of emotion by the patient.
Emotional levels that are too high or too low are likely to interfere with therapy. The therapist must also
be able to deal effectively with emotional issues which interfere with effective change (e.g. hostility,
anxiety, excessive anger). Effective facilitation will enable the patient to access and express his/her
emotions in a way that facilitates change.

Three features have to be considered:

(i) facilitation of access to a range of emotions;

(ii) appropriate use and containment of emotional expression;
(iii) facilitation of emotional expression; encouraging appropriate access and differentiation of
emotions.

Competence Examples
Level NB. Score according to features, not examples!

0 Patient is under- or over stimulated (e,g, his her feelings are ignored or dismissed or
allowed to reach an unmanaged pitch). Or the therapist’s own mood or strategies (e.e.
intellectualization) adversely influences the session.

1 Failure to facilitate access to, and expression of, appropriate emotional expression.

Facilitation of appropriate emotional expression evident, but many relevant

2 opportunities missed.

Some effective facilitation of appropriate emotional expression, created and/or

3 maintained. Patient enabled to become slightly more aware.

4 Effective facilitation of appropriate emotional expression leading to the patient

becoming more aware of relevant emotions. Minor problems evident.

5 Very effective facilitation of emotional expression, optimally arousing the patient’s

motivation and awareness. Good expression of relevant emotions evident- done in an
effective manner. Minimal problems.

6 Excellent facilitation of appropriate emotional expression, or effective facilitation in the

face of difficulties

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ITEM.7 - ELICITING KEY COGNITIONS

Key features: To help the patient gain access to his/her cognitions (thoughts, assumptions and
beliefs) and to understand the relationship between these and their distressing emotions. This can be
done through the use of questioning, diaries and monitoring procedures.

Three features need to be considered:

(i) eliciting cognitions that are associated with distressing emotions (i.e. selecting key cognitions
or hot thoughts);
(ii) the skillfulness and breadth of the methods used (i.e. Socratic questioning; appropriate
monitoring, downward arrowing, imagery, role-plays, etc.);
(iii) choosing the appropriate level of work for the stage of therapy (i.e. automatic thoughts,
assumptions, or core beliefs).

NB: This item is concerned with the general work done with eliciting cognitions. If any specific
cognitive or behavioural change methods are used, they should be scored under item 1 1
(change methods).

Competence Examples
level NB: Score according to features, not examples!

0 Therapist fails to elicit relevant cognitions.

1 Inappropriate cognitions and emotions selected, or key cognitions/emotions

ignored.

2 Some cognitions/emotions (or one key cognition, e.g. core belief) elicited, but
links between cognitions and emotions not made clear to patient.

3 Some cognitions/emotions (or one key cognition) elicited in a competent way,

although some problems evident.

A number of cognitions and emotions (or one key cognition) elicited in verbal or
4
written form, leading to a new understanding of their relationship. Minor
problems evident.

Effective eliciting and selection of a number of cognitions/emotions (or one key

5 cognition), which are generally dealt with appropriately. Minimal problems.

6 Excellent work done on key cognition(s) and emotion(s), even in the face of
difficulties.

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ITEM 8 - ELICITING AND PLANNING BEHAVIOURS

Key features: To help the patient gain insight into the effect of his/her behaviours with respect to the
problems. This can be done through the use of questioning; diaries and monitoring procedures. The
therapist works with the patient to plan strategies either to overcome or disrupt dysfunctional
behavioural patterns.

Two features need to be considered:

(i) eliciting behaviours and plans that are associated with distressing emotions;
(ii) the skilfulness and breadth of the methods used (i.e. Socratic questioning; appropriate
monitoring, downward arrowing, imagery, role-plays, etc.);

NB: This item is concerned with the general work done with eliciting behaviours and plans. If any
specific cognitive or behavioural change methods are used, they should be scored under item
1 1 (change methods).

Competence Examples
level NB: Score according to features, not examples!

0 Therapist fails to elicit relevant behaviours and plans.

1 Inappropriate behaviours focused on and/or plans generated.

Some behaviours and plans elicited, but links between behaviours, cognitions
2 and emotions not made clear to patient.

3 Some behaviours and plans elicited in a competant way, although some

problems evident.

A number of behaviours and plans elicited in verbal or written form, leading to a

4
new understanding of their importance in maintaining problems. Minor
difficulties evident.

Effective eliciting and selection of a number of behaviours and plans, which are
5 generally dealt with appropriately. Minimal problems.

6 Excellent work done on behaviours and plans, even in the face of difficulties.

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ITEM 9 - GUIDED DISCOVERY

Key features: The patient should be helped -to -develop hypotheses regarding his/her current
situation and to generate potential solutions' for him/herself. The patient is helped to develop a range
of perspectives regarding his/her experience. Effective guided discovery will create doubt where
previously there was certainty, thus providing the opportunity for re-evaluation and new learning to
occur.

Two elements need to be considered:

(i) the style of the therapist - this should [Link] and inquisitive;
(ii) the effective use of questioning techniques (e.g. Socratic questions) should encourage the
patient to discover useful information that can be used to help him/her to gain a better level of
understanding.

Competence Examples
level NB: Score according to features, not examples!

0 No attempt at guided discovery (e.g. hectoring and lecturing).

1 Little opportunity for discovery by patient. Persuasion and debate used

excessively.

Minimal opportunity for discovery. Some use of questioning, but unhelpful in

2
assisting the patient to gain access to his/her thoughts or emotions or to
make connections between themes.

Some reflection evident. Therapist uses primarily a questioning style which is

3 following a productive line of discovery.

Moderate degree of discovery evident. Therapist uses a questioning style

4 with skill, and this leads to some synthesis. Minor problems evident.

Effective reflection evident. Therapist uses skilful questioning style leading to

5 reflection, discovery, and synthesis. Minimal problems.

Excellent guided discovery leading to a deep patient understanding. Highly

6 effective discovery produced in the face of difficulties, with evidence of a
deeper understanding having been developed.

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ITEM 10 - CONCEPTUAL INTEGRATION

Key features: The patient should be helped to gain an appreciation of the history, triggers and
maintaining features of his/her problem in order to bring about change in the present and future. The
therapist should help the patient to gain an understanding of how his/her perceptions and
interpretations, beliefs, attitudes and rules relate to his/her problem. A good conceptualisation will
examine previous cognitions and coping strategies as well as current ones. This theory-based
understanding should be well integrated and used to guide the therapy forward.

Two features need to be considered:

(i) the presence/absence of an appropriate conceptualisation which is in line with goals of

therapy;
(ii) the manner in which the conceptualisation is used (e.g. used as the platform for interventions,
homework etc.).

NB: This item is to do with therapeutic integration (using theory to link present, past and future). If
the therapist deals specifically with cognitions and emotions, this should be scored under Items 6
(Facilitation of Emotional Expression) and 7 (Eliciting Key of Cognitions)

Competence Examples
level NB: Score according to features, not examples!

0 The absence of an appropriate conceptualisation.

The lack, or inappropriateness or misapplication of a conceptualisation leads

to a neutral impact (e.g. interferes with progress or leads to aimless application
1 of procedures).

2 Some rudimentary conceptualisation arrived at, but not well integrated with
goals of therapy. Does not lead to a clear rationale for interventions.

3 Cognitive conceptualisation partially developed with some integration, but

some difficulties evident (e.g. in synthesising and in sharing it with the
patient). Leads to coherent interventions.

Cognitive conceptualisation is moderately developed and integrated within

4
the therapy. Minor problems evident.

Cognitive conceptualisation is very well developed and integrated within the

5 therapy - there is a credible cognitive understanding leading to major
therapeutic shifts. Minimal problems.

Excellent development and integration evident, or highly effective in the

6 face of difficulties.

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ITEM 11- APPLICATION OF CHANGE METHODS

Key features: Therapist skillfully uses, and helps the patient to use, appropriate cognitive and
behavioural techniques in line with the formulation. The therapist helps the patient devise appropriate
cognitive methods to evaluate the key cognitions associated with distressing emotions, leading to
major new perspectives and shifts in emotions. The therapist also helps the patient to apply
behavioural techniques in line with the formulation. The therapist helps the patient to identify potential
difficulties and think through the cognitive rationales for performing the tasks. The methods provide
useful ways for the patient to test-out cognitions practically and gain experience in dealing with high
levels of emotion. The methods also allow the therapist to obtain feedback regarding the patient's
level of understanding of prospective practical assignments (i.e. by the patient performing the task
in- session).

Three features need to be considered:

(i) the appropriateness and range of both cognitive methods (e.g. cognitive change diaries,
continua, distancing, responsibility charts, evaluating alternatives, examining pros and cons,
determining meanings, imagery restructuring, etc.) and behavioural methods (e.g. behavioural
diaries, behavioural tests, role play, graded task assignments, response prevention,
reinforcement of patient's work, modeling, applied relaxation, controlled breathing, etc.);
(ii) the skill in the application of the methods - however, skills such as feedback, interpersonal
effectiveness, etc. should be rated separately under their appropriate items;
(iii) the suitability of the methods for the needs of the patient (i.e. neither too difficult nor complex).

NB: This item is not concerned with accessing or identifying thoughts, rather with their re-evaluation.

Competence Examples
level NB: Score according to features, not examples!

0 Therapist fails to use or misuses appropriate cognitive and behavioural

methods.

1 Therapist applies either insufficient or inappropriate methods, and/or with

limited skill or flexibility.

Therapist applies appropriate methods, but major difficulties evident.

2

3 Therapist applies a number of methods in competent ways, although some

problems evident (e.g. the interventions are incomplete).

4 Therapist applies a range of methods with skill and flexibility, enabling the
patient to develop new perspectives. Minor problems evident.

5 Therapist systematically applies an appropriate range of methods in a

creative, resourceful and effective manner. Minimal problems.

Excellent range and application, or successful application in the face of

6
difficulties.

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ITEM 12 - HOMEWORK SETTING

Key features: This aspect concerns the setting of an appropriate homework task, one with clear and
precise goals. The aims should be to negotiate an appropriate task for the stage of therapy in line
with the conceptualisation; to ensure the patient understands the rationale for undertaking the task;
to test out ideas, try new experiences, predict and deal with potential obstacles, and experiment with
new ways of responding.

There are three aspects to this item:

(i) presence/absence of a homework task in which clear and precise goals have been set;
(ii) the task should be derived from material discussed in the session, such that there is a clear
understanding of what will , be learnt from performing the task;
(iii) the homework task should be set jointly, and sufficient time should be allowed for it to be
explained clearly (i.e. explain, discuss relevance, predict obstacles, etc.).

NB: Review of homework from the previous session should be rated in Item 1(Agenda Setting)

Competence Examples
level NB: Score according to features, not examples!

0 Therapist fails to set homework, or sets inappropriate homework.

1 Therapist does not negotiate homework. Insufficient time allotted for

adequate explanation, leading to ineffectual task being set.

2 Therapist negotiates homework unilaterally and in a routine fashion,

without explaining the rationale for new homework.

3 Therapist has set an appropriate new homework task, but some problems
evident (e.g. not explained sufficiently and/or not developed jointly).

4 Appropriate new homework jointly negotiated with a clear goals and

rationales. However, minor problems evident.

Appropriate homework negotiated jointly and explained well, including an

5
exploration of potential obstacles. Minimal problems.

Excellent homework negotiated, or appropriate one set in the face of

6
difficulties.

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