CBT Basics and

The Cognitive Therapy

Rating Scale
Leslie Sokol, Ph.D.
Distinguished Founding Fellow,
Academy of Cognitive Therapy
 The Cognitive Model

Situation Automatic Thoughts Emotion

One’s perception of a situation leads to automatic thoughts which then influence emotion

Emotion
Situation Automatic Thoughts Behavior
Physiological
Response
Automatic thoughts influence not only one’s emotional
response, but also one’s behavioral and physiological
responses

Situation Automatic Thoughts Emotion

Beliefs
One’s perception and thoughts are influences by underlying beliefs.
©1995 JSBeck, Cognitive Therapy: Basics and Beyond, Guilford.
Definition of Cognitive Therapy
Cognitive Therapy is a focused form of
psychotherapy based on a model stipulating that
psychological disorders involved dysfunctional
thinking.
– Depression: Negative Bias
– Anxiety: Exaggerated and inaccurate perceptions of
danger and minimized inaccurate perceptions of
resources
– Anger: Unfulfilled demanding shoulds on self and
others lead to anger and frustration but the hurt and
fear beneath the anger comes from the meaning of
the demand not being met
– Psychosis: It is not the hallucination or the delusion
that creates distress but the meaning ascribed to it
COGNITIVE TRIAD
Paralysis
Negative
of Will
Self
View Depressed
Mood

Suicidal
Negative
Wishes
View of
Future Increased
Dependency

Negative
Avoidance
View of
Wishes
World
Modifying dysfunctional thinking provides
improvement in symptoms.

Modifying dysfunctional beliefs which

underlie dysfunctional thinking leads to
more durable improvement.
 Beliefs
The way an individual feels and behaves
is influenced by the way he structures his
experiences.
 Cognitive Conceptualization Diagram
RELEVANT CHILDHOOD DATA

CORE BELIEFS

CONDITIONAL ASSUMPTIONS/ BELIEFS/ RULES

COPING STRATEGIES

SITUATION #1 SITUATION #2 SITUATION #3

AUTOMATIC THOUGHT AUTOMATIC THOUGHT AUTOMATIC THOUGHT

MEANING OF AT MEANING OF AT MEANING OF AT

Emotion Emotion Emotion

Behavior Behavior Behavior
© 2011, Beck, J.S. Cognitive Behavior Therapy: Basics and Beyond (2nd ed.). www.beckinstitute.org.
Cognitive Therapy treatment involves a cognitive
conceptualization of the disorder and of the
particular patient and uses a variety of
techniques: cognitive, behavioral, experiential,
pharmacological, brain stimulation, exposure,
etc.
NOTE: The techniques are limitless as the key is
in the conceptualization of the problem, the
strategy for intervention and the rationale for the
technique used.
 Principles of Cognitive Therapy
Cognitive Therapy is based on the cognitive
model:
Thoughts influence emotion.

Cognitive Therapy has the following

characteristics:
Goal Directed/Structured/Time limited
Present-oriented/Past aware
Collaborative
Educative (psychological model of coping)
Techniques are unlimited (cog,beh,etc.)
 Key Features of Treatment
• Cognitive Conceptualization
• Thorough diagnostic evaluation
• Strong Therapeutic Alliance
• Agenda-Structure
• Problem Solving Orientation
• Evaluation of Thoughts and Beliefs
• Capsule and General Summaries
• Homework
• Relapse Prevention
 Structure of the Therapeutic Interview

1. Mood check
2. Setting agenda
3. Bridge from last session
4. Discussion of today’s agenda items
5. Homework assignment
6. Capsule summaries plus summarization
of session
7. Feedback from patient
 Psychometric Findings on the
Cognitive Therapy Scale
Reliability
Strunk et al. (2002) reported
findings from a recent large multi-
site RCT of cognitive therapy for
depression. Two experts in CT
rated 12 audiotapes and two
graduate students rated 170
tapes.
 Reliability
Reliability Student Ratings Expert
Ratings
Estimates___________________________
_____

Intraclass
Correlation Coefficient .70 .86

Internal Consistency .95 .95

(Cronbach’s alpha)
 Validity
Shaw et al. (1999) reported findings
from the NIMH Treatment of
Depression Collaborative Research
Program (TDCRP). Two experts
made CTS ratings of 302 sessions
across 36 depressed patients.
Patient’s level of depression was
measured using the Hamilton Rating
Scale of Depression (HRSD).
 Validity
Finding: Patient’s showed an
average decrease of about 12
points on the HTRS from pre-
treatment to termination. A
multiple regression analysis
showed the CTS scores
accounted for 15% of this change.
 References
Dobson, K.S. et al. (1985)
Shaw, B.F. et al. (1999)
Strunk, D.R. et al. (2002)
Vallis, T.M. et al. (1986)
Williams, R.M. et al. (1991)
Cognitive Therapy Rating Scale
Agenda
Feedback
Understanding
Interpersonal Effectiveness
Collaboration
Cognitive Therapy Rating Scale
Pacing and Efficient Use of Time
Guided Discovery
Focusing on Key Cognitions/Behaviors
Strategy for Change
Application of techniques
Homework
Cognitive Therapy Rating Scale

Poor Barely Adequate Mediocre Satisfactory Good Very Good Excellent

0 1 2 3 4 5 6

Part 1. General Therapeutic Skills

___1. AGENDA
0 Therapist did not set agenda

2 Therapist set agenda that was vague or incomplete

4 Therapist worked with patient to set a mutually satisfactory

agenda that included specific target problems (e.g., anxiety at
work, dissatisfaction with marriage.)

6 Therapist worked with patient to set an appropriate agenda with

target problems, suitable for the available time. Established
priorities and then followed agenda.
___2. FEEDBACK (SUMMARY)
0 Therapist did not ask for feedback to determine patient’s
understanding of, or response to, the session.

2 Therapist elicited some feedback from the patient, but did not ask
enough questions to be sure the patient understood the
therapist’s line of reasoning during the session or to ascertain
whether the patient was satisfied with the session.

4 Therapist asked enough questions to be sure that the patient

understood the therapist’s line of reasoning throughout the
session and to determine the patient’s reactions to the session.
The therapist adjusted his/her behavior in response to the
feedback, when appropriate.

6 Therapist was especially adept at eliciting and responding to

verbal and non-verbal feedback throughout the session (e.g.,
elicited reactions to session, regularly checked for understanding,
helped summarize main points at end of session.
___3. UNDERSTANDING

0 Therapist repeatedly failed to understand what the patient

explicitly said and this consistently missed the point.
Poor empathetic skills.

2 Therapist was usually able to reflect or rephrase what the patient

explicitly said, but repeatedly failed to respond to more subtle
communication. Limited ability to listen and empathize.

4 Therapist generally seemed to grasp the patient’s “internal

reality” as reflected by both what the patient explicitly said and
what the patient communicated in more subtle ways. Good
ability to listen and empathize.

6 Therapist seemed to understand the patient’s “internal reality”

thoroughly and was adept at communication this understanding
through appropriate verbal and non-verbal responses to the
patient (e.g., the tone of the therapist’s response conveyed a
sympathetic understanding of the patient’s “message”.
Excellent listening and empathic skills
___4. INTERPERSONAL EFFECTIVENESS

0 Therapist had poor interpersonal skills. Seemed hostile,

demeaning, or in some other way destructive to the
patient.

2 Therapist did not seen destructive, but had significant

interpersonal problems. At times, therapist appeared
unnecessarily inpatient, aloof, insincere or had difficulty
conveying confidence and competence.
4 Therapist displayed a satisfactory degree of warmth,
concern, confidence, genuineness, and
professionalism. No significant interpersonal
problems.

6 Therapist displayed optimal levels of warmth, concern,

confidence, genuineness, and professionalism,
appropriate for this particular patient in this session.
___5. COLLABORATION

0 Therapist did not attempt to set up a collaboration with

patient

2 Therapist attempted to collaborate with patient, but had

difficulty either defining a problem that the patient
considered important, or establishing rapport.

4 Therapist was able to collaborate with patient, focus on

a problem that both patient and therapist considered
important, and establish rapport.

6 Collaboration seemed excellent; therapist encouraged

patient as much as possible to take an active role
during the session (e.g. by offering choices) so
they could function as a “team”.
___6. PACING AND EFFICIENT USE OF TIME

0 Therapist made no effort to structure therapy time. Session

seemed aimless.

2 Session had some direction, but the therapist had significant

problems with structuring or pacing (e.g., too little structure,
inflexible about structure, too slowly paced, too rapidly
paced).

4 Therapist was reasonably successful at using time

efficiently. Therapist maintained appropriate control over
flow of discussion and pacing.

6 Therapist used time efficiently by tactfully limiting peripheral

and unproductive discussion and by pacing the session as
rapidly as was appropriate for the patient.
Part II CONCEPTUALIZATION, STRATEGY, AND TECHNIQUE

___7. GUIDED DISCOVERY

0 Therapist relied primarily on debate, persuasion, or
“lecturing”. Therapist seemed to be “cross-examining”
patient, putting the patient on the defensive, or forcing
his/her point of view on the patient.

2 Therapist relied too heavily on persuasion and debate, rather

than guided discovery. However, therapist’s style was
supportive that patient did not seem to feel attacked or
defensive.

4 Therapist, for the most part, helped patient see new

perspectives through guided discovery (e.g., examining
evidence, considering alternatives, weighing advantages and
disadvantages) rather than through debate. Used
questioning appropriately.

6 Therapist was especially adept at using guided discovery during

the session to explore problems and help patient draw his/her
own conclusions. Achieved an excellent balance between skillful
questioning and other modes of intervention.
___8. FOCUSING ON KEY COGNITIONS OR BEHAVIORS

0 Therapist did not attempt to elicit specific thoughts,

assumptions, images, meanings, or behaviors.

2 Therapist used appropriate techniques to elicit cognitions or

behaviors; however, therapist had difficulty finding a focus or
focused on cognitions/behaviors that were irrelevant to the
patients key problems.

4 Therapist focused on specific cognitions or behaviors

relevant to the target problem. However, therapist could
have focused on more central cognitions or behaviors that
offered greater promise for progress.

6 Therapist very skillfully focused on key thoughts,

assumptions, behaviors, etc. that were most relevant to the
problem area offered considerable promise for progress.
___9. STRATEGY FOR CHANGE (Note: For this item, focus on the quality
of the therapist’s strategy for change, not on how effectively the
strategy was implemented or whether change actually occurred.)

0 Therapist did not select cognitive-behavioral techniques.

2 Therapist selected cognitive-behavioral techniques; however,

either the overall strategy for bringing about change seemed
vague or did not seem promising in helping the patient.

4 Therapist seemed to have a generally coherent strategy for

change that showed reasonable promise and incorporated
cognitive-behavioral techniques.

6 Therapist followed a consistent strategy for change that

seemed very promising and incorporated the most
appropriate cognitive-behavioral techniques.
___10. APPLICATION OF COGNITIVE-BEHAVIORAL TECHNIQUES
(Note: For this item, focus on how skillfully the techniques were
applied, not on how appropriate they were for the target
problem or whether change actually occurred.)

0 Therapist did not apply any cognitive-behavioral

techniques.

2 Therapist used cognitive-behavioral techniques, but

there were significant flaws in the way they were
applied.

4 Therapist applied cognitive-behavioral techniques with

modern skill.

6 Therapist very skillfully and resourcefully employed

cognitive-behavioral techniques.
___11. HOMEWORK

0 Therapist did not attempt to incorporate homework relevant

to cognitive therapy.

2 Therapist had significant difficulties incorporating homework

(e.g., did not review previous homework in sufficient detail,
assigned inappropriate homework).

4 Therapist reviewed previous homework and assigned

“standard” cognitive therapy homework generally relevant to
issues dealt with in session. Homework was explained in
sufficient detail.

6 Therapist reviewed previous homework and carefully

assigned homework drawn from cognitive therapy for the
coming week. Assignment seemed “custom tailored” to help
patient incorporate new perspectives, test hypotheses,
experiment with new behaviors discussed during sessions,
etc.
Importance of Homework

Extends therapy contact

Test of patient motivation
Opportunity to Practice
Continuity between Session
Data gathering
Significant others
Relapse Prevention
 INCREASING HOMEWORK
COMPLIANCE
1. Set homework collaboratively.

2. Provide rationale (or ask client what rationale is).

3. Provide explicit instructions (including time,

place, frequency, duration, etc., if applicable).
Insure that patient is capable of doing
assignment.
Start assignment in session, if applicable.

4. Ask client how likely he/she is to do it.

Questions
And
Answers
 References

Beck, A.T., &Alford, B.A. (2008) Depression: Causes and

treatment, 2nd edition. Philadelphia: University of
Pennsylvania Press.
Beck, J.S. (2011)2nd edition. Cognitive therapy: Basics
and beyond. New York: Guilford.
Clark, D.A., and Beck, A.T. (2012). The anxiety and worry
workbook: The cognitive behavioral solution. New York:
Guilford.
Clark, D.A., and Beck, A.T. (2011). Cognitive therapy of
anxiety disorders: Science and practice. New York:
Guilford.
 References Continued
Fox, M.G. & Sokol, L. (2011) Think Confident, Be Confident
for Teens: A cognitive therapy program to eliminate
doubt and create unshakeable self-confidence. Oakland,
CA: New Harbinger.
Hofmann, S.G. (2011) An introduction to modern CBT:
Psychological solutions to mental health problems.
Oxford: John Wiley &Sons.
Sokol, L. & Fox, M.G. (2009) Think Confident, Be
Confident: A four step program to eliminate doubt and
achieve lifelong self-esteem. New York: Perigee.
Wenzel, A., Brown, G., &Beck, A.T. (2009) Cognitive
Therapy for Suicidal Patients: Scientific and Clinical
Applications. American Psychological Association
 Contact Dr. Sokol
Opportunities in Supervision and Training

www.cbtexperts.com
Email: lsokol3@aol.com
Certification and Referrals in
Cognitive Behavior Therapy

www.academyofct.org