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Cognitive Therapy Scale � Revised
This scale is a modified version of the Newcastle Cognitive Therapy Scale � Revised (Blackburn et al 2001) and is suitable for screening OSCEs.
Items
Session orientation and structure
Feedback
Collaborative language and behaviour
Pacing and efficient use of time
Interpersonal effectiveness
Use of CBT assessment model
Questioning skills
Risk assessment
Conceptual integration
Session closure
As a general rule, scoring should be used as follows, but please note the key features for each item:
Competence levelScore Description Incompetent 0Absence of feature, or highly inappropriate performance
Incompetent / Novice1Inappropriate performance, with major problems evident
Novice / Advanced beginner2Evidence of competence, but numerous problems and lack of consistency Advanced beginner / Competent3Competent, but some problems and/or inconsistenciesCompetent / Proficient4Good features, but minor problems and/or inconsistencies
Proficient / Expert5Very good features, minimal problems and/or inconsistencies
Expert 6Excellent performance, even in the face of patient difficulties
Item 1: Session orientation and structure
Key features:
This needs to include mention of the main aim of the session (assessing the suitability of CBT for the patient抯 problems), confidentiality (including its limits), and consent for any recording. The patient抯 preferred name should be established, and the therapist抯 name and role should be mentioned, as should the duration of the session. The format of the session should be outlined in brief (asking questions about the main problem, feeding back the therapist抯 understanding, and agreeing on what might be maintaining the problem) and this format should be adhered to.
Competence levelScore Description Incompetent 0No introduction to the session, highly inappropriate introduction, or format not adhered to at all.
Incompetent / Novice1Inappropriate introduction to the session or inappropriate format set (e.g. lack of focus, unrealistic).
Novice / Advanced beginner2An attempt at an introduction to the session made, but major difficulties evident (e.g. suitability not mentioned). Poor adherence to format.
Advanced beginner / Competent3Appropriate introduction to the session, which was carried out well, but some omissions evident. Some adherence to the format.
Competent / Proficient4Appropriate introduction and format, minor difficulties evident (e.g. no mention of duration), but appropriate features covered (e.g. confidentiality). Moderate adherence.Proficient / Expert5Appropriate introduction and format with all relevant aspects covered. Format adhered to. Minimal problems.
Expert 6Excellent introduction and format, with everything covered very well, even in the face of difficulties.
Item 2: Feedback
Key features:
The patient抯 and therapist抯 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 the therapist to understand the patient抯 situation, and the patient to stay focused.
Features to be considered:
Frequency of feedback
Appropriateness of the contents of the feedback
Manner of its delivery and elicitation
Competence levelScore Description Incompetent 0Absence of feedback or highly inappropriate feedback.
Incompetent / Novice1Minimal appropriate feedback.
Novice / Advanced beginner2Appropriate 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. Advanced beginner / Competent3Appropriate feedback given and elicited frequently, although some difficulties evident in terms of content or method of delivery.
Competent / Proficient4Appropriate feedback given and elicited frequently. Minor problems evident (e.g. inconsistent).
Proficient / Expert5Highly appropriate feedback given and elicited regularly, facilitating shared understanding. Minimal problems.
Expert 6Excellent use of feedback, or highly effective feedback given and elicited regularly, even in the face of difficulties.
Item 3: Collaborative language and behaviour
Key features:
The therapist抯 stance should be collaborative throughout the session, rather than being either, on the one hand, controlling or, on the other, non-directive. Language involving words and phrases such as 憌e�, 憉s�, and 憌orking together�, and behaviour such as offering choice, and sitting alongside the patient to share a diagrammatic formulation, are all examples of taking a collaborative stance.
Features to be considered:
Verbal skills
Non-verbal skills
Shared written materials
Competence levelScore Description Incompetent 0Patient is actively prevented or discouraged from being collaborative.
Incompetent / Novice1The therapist is too controlling, dominating, or passive.
Novice / Advanced beginner2Some occasional attempt at collaboration, but didactic style or passivity of therapist encourages passivity or other problems in the therapeutic relationship.
Advanced beginner / Competent3Collaborative stance evident, but some problems (e.g. therapist is verbally collaborative, but insufficient attention paid to patient抯 responses).
Competent / Proficient4Collaborative stance is evident, but not consistent. Minor problems evident.
Proficient / Expert5Very good use of collaborative language and behaviour throughout most of the session, both verbally and non-verbally. Minimal problems.
Expert 6Excellent use of collaborative language and behaviour to encourage patient involvement, even in the face of patient difficulties.
Item 4: Pacing and efficient use of time
Key features:
The session should be well 憈ime 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抯 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.
Features to be considered;
The degree to which the session flows smoothly through the discrete phases.
The appropriateness of the pacing throughout the session.
The degree of fit to the learning speed of the patient.
Competence levelScore Description Incompetent 0Poor time management leads either to an aimless or overly rigid session.
Incompetent / Novice1The session is too slow or too fast for the current needs and capacity of the patient.
Novice / Advanced beginner2Reasonable pacing, but digression or repetitions from therapist and/or patient lead to inefficient use of time, session runs over time.
Advanced beginner / Competent3Good pacing evident some of the time, but diffuse at times. Some problems evident.
Competent / Proficient4Balanced allocation of time with discrete start, middle and concluding phases evident. Minor problems evident.
Proficient / Expert5Good time management skills evident, session running smoothly. Therapist working effectively in controlling the flow within the session. Minimal problems.
Expert 6Excellent time management, or highly effective management evident even in the face of difficulties.
Item 5: Interpersonal effectiveness
Key features:
The patient is put at ease by the therapist抯 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 s/he is creative, insightful and inspirational.
Features to be considered:
Empathy � the therapist is able to understand and enter the patient抯 feelings imaginatively and uses this understanding to promote the alliance.
Genuineness � the therapist has established a trusting working relationship.
Warmth � the patient seems to feel liked and accepted by the therapist.
Competence levelScore Description Incompetent 0Therapist抯 manner and interventions make the patient disengage and become distrustful and/or hostile (absence of empathy, genuineness, warmth).
Incompetent / Novice1Difficulty in showing empathy, genuineness and warmth.
Novice / Advanced beginner2Therapist抯 style (e.g. intellectualisation) at times impedes her/his empathic understanding of the patient抯 communications.
Advanced beginner / Competent3The therapist is able to understand explicit meanings of patient抯 communications, resulting in some trust developing. Some evidence of inconsistencies in sustaining relationship.Competent / Proficient4The therapist is able to understand the implicit, as well as the explicit meanings of the patient抯 communications and demonstrates it in her/his manner. Minor problems evident (e.g. inconsistent). Proficient / Expert5The therapist demonstrates very good interpersonal effectiveness. Patient appears confident that s/he is being understood, which facilitates self-disclosure. Minimal problems.Expert 6Highly interpersonally effective, even in the face of difficulties.
Item 6: Use of CBT assessment model
Key features:
The therapist should use a CBT model as the basis for the way in which s/he gathers information about the patient抯 problem(s). This includes a focus on key cognitions and key behaviours that may be maintaining the problem, as well as emotions and bodily symptoms. In addition, attention should be paid to triggers that tend to set off the problem, and both short- and long-term consequences of attempts to cope.
Features to be considered:
Attention paid to 慿ey� cognitions that seem particularly relevant in precipitating or perpetuating the problem.
Congruence between 慿ey� cognitions and the most problematic emotions.
Attention paid to 慿ey� behaviours that are making the problem worse in the longer term.
Competence levelScore Description Incompetent 0Therapist fails to elicit relevant emotions, cognitions or behaviours.
Incompetent / Novice1Inappropriate emotions, cognitions and behaviours focused on, or key ones ignored.
Novice / Advanced beginner2Some emotions, cognitions and behaviours elicited, but links between them are not made clear to patient.
Advanced beginner / Competent3Some emotions, cognitions and behaviours elicited in a competent way, although some problems evident.
Competent / Proficient4A number of emotions, cognitions and behaviours elicited, leading to some understanding of their relationship to each other. Minor problems evident.
Proficient / Expert5Effective eliciting and selection of a number of emotions, cognitions and behaviours, including how they relate to one another. Minimal problems.
Expert 6Excellent eliciting of key emotions, cognitions and behaviours, even in the face of difficulties.
Item 7: Questioning skills
Key features:
The therapist should ask predominantly open questions that follow on sequentially from one another. These should be phrased as simply as possible, so that they are easily understood. Multiple, closed and leading questions should be avoided. Questions asked should all be relevant to ascertaining the nature of the main problem or assessing level of risk. They should be sufficient to allow a basic understanding of the patient抯 difficulties. To avoid the questioning feeling like interrogation, summaries should be used regularly.
Features to be considered:
The extent to which most of the questions are open in nature and relevant to the assessment.
How much questions follow on logically from one another and from the patient抯 responses.
Use of summaries to provide breaks in continuous questioning.
Competence levelScore Description Incompetent 0No questions asked, or only inappropriate questions asked.
Incompetent / Novice1Very few questions asked, most of which are irrelevant to an initial assessment.
Novice / Advanced beginner2Some relevant questions asked, but many are closed and leading. Patient抯 initial answers are not explored further.
Advanced beginner / Competent3Some good open questions asked, but too many closed questions. Insufficient summarising means the questioning sounds like an interrogation.
Competent / Proficient4Good use of questioning, with more open than closed questions, and occasional summaries. Minor problems evident (e.g. some multiple questions).
Proficient / Expert5Very good use of mostly open questions, with regular summaries. Minimal problems.
Expert 6Excellent use of sequential relevant open questions and summaries, even in the face of patient difficulties
Item 8: Risk assessment
Key features:
The therapist should ascertain the level of risk posed by the patient抯 current difficulties. Central to this is an assessment of mental state, particularly in terms of depressed mood. Suicide risk should always be checked. It is often important to ask about possible risk to others, either through violence or neglect, especially where children or older people are involved. Further exploration of risk factors will depend on the patient抯 responses; this is one example of when a session may not finish on time, if there are important risk issues that need to be assessed in greater detail. Substance usage should also be assessed routinely, including use of alcohol, prescribed medication, and illegal drugs.
Features to be considered:
Assessment of the risk of self-harm.
Assessment of the extent to which the patient is a danger to others.
Substance usage risk factors.
Competence levelScore Description Incompetent 0No assessment undertaken of any risk factors.
Incompetent / Novice1Some attempt made at risk assessment, but with major omissions, e.g. inadequate assessment of suicide risk.
Novice / Advanced beginner2Some areas of risk assessed well, but others neglected or inadequately assessed.
Advanced beginner / Competent3Competent risk assessment carried out, but more detail needed, e.g. quantity of alcohol drunk each week.
Competent / Proficient4Good assessment of all risks. Minor problems, such as omitting dosage of medication.
Proficient / Expert5Very good assessment of all risks, integrated well into the session. Minimal problems.
Expert 6Excellent assessment of all possible risks, even in the face of patient difficulties
Item 9: Conceptual integration
Key features:
The patient should be helped to gain a rudimentary understanding of some of the maintaining factors of his/her problem. The therapist should do this through use of a diagrammatic initial formulation that includes at least one 憊icious cycle� and that is shared with the patient.
Features to be considered:
Whether a diagram is used to illustrate the conceptualisation
The extent to which maintaining cycles are consistent with CBT theory.
Competence levelScore Description Incompetent 0No attempt made to summarise or conceptualise the patient抯 problem.
Incompetent / Novice1Some conceptualisation evident, but no attempt made to draw a diagram, or links between symptoms are inconsistent with CBT theory.
Novice / Advanced beginner2Conceptualisation evident, but no clear sense of a 憊icious cycle� (e.g. only the 慼ot-cross bun� model is used).
Advanced beginner / Competent3One maintenance cycle clearly elicited and shared with the patient, although other maintaining factors are ignored.
Competent / Proficient4Good conceptualisation of maintaining factors. Minor problems evident, such as double-headed arrows.
Proficient / Expert5Very good conceptualisation of a number of maintenance cycles. Minimal problems.
Expert 6Excellent conceptualisation of maintaining factors, even in the face of difficulties.
Item 10: Session closure
Key features:
The therapist should bring the session to a close by summarising the patient抯 main problem, making a clear statement regarding suitability of the CBT approach, inviting questions from the patient, and asking for feedback on how the patient has found the session.
Features to be considered:
Whether the main problem is succinctly summarised.
Whether a statement is made regarding suitability of CBT.
The extent to which patient feedback is sought and questions are invited.
Competence levelScore Description Incompetent 0The session finishes without the therapist covering any of the key areas.
Incompetent / Novice1Inappropriate closure to the session, abrupt ending.
Novice / Advanced beginner2Some evidence of session closure, but many difficulties (e.g. no mention of suitability or no summary of the problem).
Advanced beginner / Competent3Competent session closure, but some problems evident (e.g. no questions invited).
Competent / Proficient4Good session closure, covering all the main points. Minor problems.
Proficient / Expert5Very good session closure. Minimal problems.
Expert 6Excellent session closure, even in the face of difficulties.
Modified CTS-R; OSCE
Name of trainee: Name of marker:
Item Score Comments 1. Session orientation and structure
2. Feedback
3. Collaborative language and behaviour
4. Pacing and efficient use of time
5. Interpersonal effectiveness
6. Use of CBT assessment model
7. Questioning skills
8. Risk assessment
9. Conceptual integration
10. Session closure
Overall mark: Pass Borderline Pass Fail
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