COGNITIVE THERAPY: CHECKLIST OF THERAPIST COMPETENCY



COGNITIVE THERAPY

FOR POST-TRAUMATIC STRESS DISORDER:

A CHECKLIST OF THERAPIST COMPETENCY (version 20/06/08)

For each item, assess the therapist on a scale of 0-6 and record the rating on the line next to the item number. Descriptions are provided for every point on the scale.

If the descriptions for a given item occasionally do not seem to apply to the session you are rating, feel free to disregard them and use the more general scale below:

0 1 2 3 4 5 6

Poor Barely Mediocre Satisfactory Good Very Excellent

Adequate Good

Failure to unhelpful/ major problems some problems/ minor minimal highly appropriate

deliver inappropriate inconsistencies, problems problems

when generally competent

indicated

or inadequate

For all items, focus on the skill of the therapist, taking into account how difficult the patient seems to be and the stage in therapy. If patient difficulties highly affect therapist ability to deliver the interventions, ratings can be elevated as appropriate. Examples are for guidance only. Please try to rate all items. Occasionally, the therapist may not use one of the general therapeutic skills or specific interventions in the session. If this seems appropriate given the content of the session and the therapist is following the treatment protocol, do not rate this as 0, but indicate N/A. The score will be the mean of the items that apply to the session.

Part 1: GENERAL THERAPEUTIC SKILLS

____ 1. SETTING THE SCENE FOR THE SESSION

At the beginning of the session, the therapist is expected to review the patient's symptom weekly measures, discuss the homework assignments from the last session and set an agenda in collaboration with the patient (following the general protocol). This will set the scene for what will be covered in the session and facilitate a shared understanding of how the session fits in with the overall treatment goals.

If there are differences in how well each of these (symptom review, homework review, agenda setting) were done, use your overall impression on how skilled the therapist was in reviewing measures, homework and setting an agenda (e.g., stronger performance in homework review may compensate for weaknesses in symptom review or agenda).

N/A: Not needed as this session was second part of day of intensive treatment

0 Failure to set scene for session: Therapist failed to collect measures, review homework, or set agenda.

1 Unhelpful/ inappropriate start of session: Therapist failed to comment on symptom measures or made unhelpful comments, therapist reviewed homework in an unhelpful way or sets inappropriate agenda (unrealistic, not take account of patient’s appraisals, not adhered to)

2 Setting scene showed major problem: Therapist made mediocre comments about symptoms, reviewed homework poorly (for example, does not elicit what patient has learned), or set an agenda with major difficulties (eg it was vague, incomplete, set without checking whether patient understands how agenda relates to treatment goals, poor adherence)

3 Therapist set the scene with satisfactory competence. Symptom measures were reviewed in a satisfactory way, but there were some problems or inconsistencies; therapist reviewed homework and noted changes, but there were some problems or inconsistencies; or therapist set an appropriate agenda, but some difficulties evident (ie poor collaboration, poor adherence)

4 Good setting the scene with minor problems: Therapist reviewed symptom measures and noted changes with minor problems; therapist reviewed homework and had some success in clarifying its outcome and what the patient had learned; therapist worked with the patient to set a mutually satisfactory agenda that included focus on specific PTSD-related targets, minor difficulties evident (eg no prioritisation) but appropriate features covered and moderate adherence.

5 Very good setting the scene with minimal difficulties: Therapist reviewed symptom measures and noted changes with minimal difficulties; therapist reviewed homework, discussed what changes, linked outcome to plan for session/ further homework, minimal difficulties; therapist set a mutually satisfactory agenda which was prioritised and reviewed at the end. Agenda adhered to, minimal difficulties.

6 Excellent setting the scene with no difficulties: Therapist reviewed changes in symptom measures with high level of skill, identified changes, reinforced progress (or planned appropriate action to deal with setbacks; therapist skilfully reviewed homework and worked with patient to maximise what could be learned from the assignment, linked outcome to plan for session/ further homework; agenda set that was highly appropriate for the available time and stage of therapy and agenda adhered to.

____ 2. QUALITY OF COMMUNICATION

0 Inadequate communication: Therapist overused jargon, was very muddled in the presentation of information or used language inappropriate to the patient. If patient raised questions, objections, doubts or problems, the therapist failed to acknowledge them, dismissed them, and made no attempt to answer them.

1 Barely adequate communication: Therapist had difficulty presenting information clearly and overused jargon or language that was very difficult for patient to understand. Therapist made minimal attempt to acknowledge questions/ objections/ problems/ doubts, but dealt with them too briefly and inappropriately.

2 Major problems in communication: Therapist presented information in a generally coherent fashion, but was overly technical and used language that was difficult for patient to understand (long complicated questions and sentences, abstract terms). Therapist showed some evidence of sensitivity to and understanding of questions/ objections/ problems/ doubts, but did not deal with them clearly and/or appropriately.

3 Satisfactory communication: Therapist presented information in a generally competent way, no overuse of jargon and generally understandable, Used examples or metaphors to illustrate points made if appropriate. Therapist was sensitive to and understood patient’s questions, objections, doubts or problems and had some success in dealing with them appropriately. Some problems or inconsistencies.

4 Good communication: Therapist presented information in a generally clear way and used language that was mostly easy for the patient to understand. Included use of stories or metaphors with some success if appropriate. Therapist was sensitive to and understood patient’s questions, objections, doubts or problems and had some success in dealing with them appropriately. Minor problems (e.g., superficial attempt to link problems back to model if indicated).

5 Very good communication: Therapist presented information in a clear and informative way and used language.that was easy for the patient to understand Used appropriate examples and metaphors to illustrate points with minimal difficulty. Therapist dealt with questions, objections, doubts or problems highly appropriately, facilitating a shared understanding. Minimal difficulties.

6 Excellent communication: Therapist presented information in a clear and well-ordered fashion and used language that was fully understandable for patient.. Used appropriate stories or metaphors if appropriate which were highly effective in illustrating specific points. Therapist dealt with questions, objections, doubts or problems excellently with sensitivity and appropriate interventions for the stage of therapy. Clearly linked questions or problems back to shared formulation (if appropriate).

____ 3. PACING AND EFFICIENT USE OF TIME

0 Therapist made no or inadequate attempt to structure therapy time. Session seemed aimless or over-rigid.

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

2 Session had some direction, but the therapist had significant problems with structuring or pacing (e.g. too little structure, too slowly paced, too rapidly paced, digression or repetition leads to inefficient use of time) Unbalanced allocation of time.

3. Good pacing evident some of the time, but diffuse at times. Generally competent use of time but some problems evident

4 Balanced allocation of time with discrete start, middle and ending. 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 pacing and time management. All agenda items covered and paced to suit individual client. Peripheral and unproductive discussion skilfully managed.

____ 4. INTERPERSONAL EFFECTIVENESS

0 Poor: Therapist had poor interpersonal skills. Seemed hostile, demeaning, or in some other way destructive to the patient.

1 Barely adequate: Difficulty in showing empathy, genuineness and warmth or conveying competence and confidence as a therapist.

2 Mediocre: Therapist’s style at times impedes his/her empathic understanding of the patient’s difficulties. At times, therapist appeared unnecessarily impatient, aloof, and insincere or had difficulty conveying confidence and competence. Major problems evident.

3 Satisfactory: Therapist displayed a satisfactory degree of warmth, concern, confidence, genuineness and professionalism. Therapist is able to understand explicit meanings of patient’s communications, resulting in some trust developing. Some evidence of inconsistencies in sustaining relationship.

4 Good: Therapist displayed a good degree of warmth, concern, confidence, genuineness and professionalism. No significant interpersonal problems. The therapist was able to understand explicit and implicit meanings of the client’s communications. Minor problems.

5 Very good: Therapist demonstrates very good interpersonal effectiveness, very good degree of warmth, concern, confidence, genuineness and professionalism. Patient appears to feel understood.. Minimal problems.

6 Excellent interpersonal effectiveness. Therapist displayed optimal levels of warmth, concern, confidence, genuineness and professionalism, appropriate for this particular patient in this session.

____ 5 GUIDED DISCOVERY

N/A Not needed in this session (eg reliving session)

0 No attempt at guided discovery. Therapist relied primarily on 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.

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

2 Minimal opportunity for discovery. Therapist relied too heavily on persuasion and debate. Some use of questioning that focused on a productive line of discovery but major problems evident.

3 Some reflection evident. Therapist uses primarily a questioning style which is following a productive line of discovery but some inconsistencies.

4 Therapist, for the most part, helped the patient see new perspectives through guided discovery (e.g. examining evidence, considering alternatives) rather than through debate. Used questioning appropriately. Minor problems evident.

5 Effective reflection evident. Therapist uses skilful questioning style leading to reflection, discovery and synthesis. Minimal problems.

6 Excellent balance between skilful questioning and other modes of intervention. Therapist was especially adept at using guided discovery during the session to explore difficulties and help patient draw own conclusions.

____ 6. ADDRESSING PATIENT'S EMOTIONS

0. Poor attention/ response to patient's emotions: The therapist does not adequately attend to or respond to patient's emotions; eg his/her feelings are ignored or dismissed or allowed to reach an unmanaged pitch. Or the therapist's own mood or strategies (eg intellectualisation) adversely influences the session.

1. Barely adequate attention/ response to patient's emotions The therapist's attention to and response to patient's emotions are barely adequate., e.g., therapist ignores important signs of patient's emotional state, failure to facilitate access to emotions, deals with emotions in an unhelpful way, or let's negative affect escalate inappropriately.

2. Major problems in attention/ response to patient's emotions. The patient attends to patient's emotions and responds to them, but there are major problems such as missing many relevant opportunities, attention to less central emotions, or poor containment of negative affect in session.

3. Satisfactory attention/ response to patient's emotions: Generally competent attention to and response to patient's emotions. Therapist leads the patient becoming somewhat more aware of relevant emotions or high affect is managed generally well, but there were some problems or inconsistencies.

4. Good attention/ response to patient's emotions: Therapist is tuned into patient's emotions and responsive to them, and effectively facilitates appropriate emotional expression. Therapist helps the patient becoming more aware of relevant emotions; or high affect is managed well. Minor problems evident.

5. Very good attention/ response to patient's emotions: Therapist is very tuned into patient's emotions and shows very appropriate responses. Very effective facilitation of expression of relevant emotions, optimally arousing the patient’s motivation and awareness of emotions; or very effective management of high negative affect. Minimal problems.

6. Excellent attention/ response to patient's emotions: Therapist responds excellently to patient's emotions. Very effective facilitation of awareness and expression of relevant emotions, even in the face of difficulties; or excellent management of high negative affect.

____ 7. USE OF EXPERIENTIAL EXERCISES TO FACILITATE COGNITIVE AND EMOTIONAL CHANGE

Experiential exercises are very useful in facilitating cognitive and emotional change in anxiety disorders. Making the patient experience the effects of behaviours or cognitions is often more convincing that Socratic dialogue on its own. Common useful examples include: thought suppression experiment to demonstrate paradoxical effects of pushing trauma memories out of one's mind, doing safety behaviours in an exaggerated fashion to demonstrate their negative effects, video-feedback, eliciting feedback from other people, role play conversation, etc. Therapists are therefore encouraged to use such exercises to help with guided discovery.

N/A: Not appropriate in this session.

0 Therapist did not use experiential exercises to facilitate cognitive and emotional change where they would have been appropriate

1 Therapist used unhelpful or inappropriate experiential exercise or did not develop appropriately with the patient was learned from the exercise

2 Therapist used experiential exercise, but there were major problems either with the exercise or with the way it was discussed afterwards

3 Therapist used satisfactory experiential exercise, but there were some problems either with the exercise or with the way it was discussed afterwards

4 Therapist used an appropriate experiential exercise, and there were minor problems either with the exercise or with the way it was discussed afterwards

5 Therapist used a highly appropriate experiential exercise, and there were minimal problems either with the exercise or with the way it was discussed afterwards

6 Excellent use of experiential exercises, therapist skilfully set up exercise and afterwards worked with patient to maximise what could be learned from the assignment, linked outcome to conceptualisation, plan for session/ further homework.

____ 8. USE OF FEEDBACK AND SUMMARIES

0 Therapist did not use summaries or ask for feedback to determine patient’s understanding of things covered during the session. Did not provide/ elicit written summary of main points from session.

1 Minimal feedback given. Unhelpful and inappropriate summaries (verbal or written). Therapist delivered feedback unilaterally and did not check for understanding

2 Therapist summaries were vague or unclear. Some feedback elicited but did not ask enough questions to be sure that the patient understood the line of reasoning or was satisfied with the session. Major problems

3 Appropriate feedback given and elicited frequently. Generally competent use of summaries although some difficulties evident in terms of content or method of delivery.

4 Therapist provided clear summaries in the session and asked sufficient questions to be sure that the patient understood the line of reasoning and to determine their response to the session. Therapist adjusted his/her behaviour in response to feedback, when appropriate. Minor problems evident (eg inconsistent or too didactic)

5 Highly appropriate feedback given and elicited regularly facilitating shared understanding and enabling significant therapeutic gains. Minimal problems.

6 Excellent summarising. Therapist was especially adept at eliciting and responding to verbal and non-verbal feedback throughout the session (e.g. regularly checked for understanding during session) The main points covered in the session were clearly summarized, asked patient to summarise at the end of the session and helped fill in any gaps in the summary). Written summary of what was learned provided if appropriate.

____ 9. HOMEWORK (other than reclaiming your life)

0 Therapist did not set any homework

1 Therapist set homework but inappropriate and unhelpful

2 Therapist set somewhat inappropriate, vague or over-general homework. Unilaterally set with little or no explanation or rationale. Major problems

3 Therapist set appropriate homework with satisfactory competence but some problems evident (not explained sufficiently and/or developed jointly)

4 Therapist set appropriate homework, jointly negotiated. Homework linked to specific work carried out in the session. Minor problems evident.

5 Appropriate homework negotiated jointly and explained well including exploring potential barriers. Minimal problems.

6 Excellent homework collaboratively negotiated. Therapist set fully appropriate homework, which was clearly explained, including potential barriers, and which followed up the issues discussed during the session in a productive way.

PTSD SPECIFIC THERAPEUTIC SKILLS

Treatment interventions in PTSD address three factors that maintain the patient's re-experiencing and other PTSD symptoms:

• work on the trauma memory;

• work on problematic appraisals of the trauma and its aftermath;

• work on cognitive and behavioural maintaining strategies that patients use to control symptoms or perceived threat.

Treatment of PTSD should always start with work on education and normalising PTSD symptoms, with reclaiming your life assignments, and with developing a shared understanding of why trauma memory work will be done.

Specific treatment techniques include:

• education/normalising of symptoms,

• reclaiming your life assignments to help patient reclaim old life and self

• developing an individualized formulation of the factors that maintain PTSD (memory, appraisal, behaviours),

• techniques to access the worst moments of trauma memory, access the meanings attached to them and reconstruct what happened (imaginal reliving, writing a trauma narrative, site visit),

• techniques to change "felt" meanings of hotspots (updating trauma memories),

• techniques to help patient identify and discriminate triggers of intrusions (stimulus discrimination)

• techniques to modifying negative appraisals related to the trauma and its sequelae (e.g., guided discovery, evidence for and against, behavioural experiments to test specific predictions in and out of session, surveys, pie charts),

• techniques to motivate and help patient drop maintaining cognitive and behavioural strategies

Most sessions should include some active therapy to address the three maintaining factors and will use a range of techniques. Not all sessions will contain all of the below, depending on the stage in therapy. Thus, the rating concentrates on the elements that were covered in the session. What was not covered should be rated as NOT APPLICABLE.

PLEASE TICK HERE THE ISSUES THAT WERE ADDRESSED / TECHNIQUES USED AND ONLY RATE THE ONES THAT APPLY TO THIS SESSION:

______ Develop/ elaborate conceptualization of patient's PTSD

_______ Reclaiming/rebuilding your life

______ Education/ normalizing

______ Memory work (imaginal reliving, updating of the trauma memory, writing narrative, stimulus

discrimination or site visit)

______ Modifying negative appraisals

______ Modifying maintaining cognitive or behavioural strategies (e.g., rumination, thought suppression,

safety behaviours)

____ 10. CONCEPTUALISATION

It is highly important when working with PTSD that therapists develop a comprehensive conceptualisation of the patient's problems in collaboration with the patient, which forms the basis of the rationale for interventions. The conceptualisation needs to

• include an explanation of the nature of the trauma memory that causes re-experiencing,

• highlight the role of the personal meaning of the event and its aftermath and

• highlight the role of maintaining behaviours and cognitive strategies such as rumination, thought suppression, and safety behaviours.

If appropriate, the conceptualisation may also include further elements such as earlier trauma, or cognitions/behaviours maintaining co-morbid problems such as panic attacks or depression. The conceptualisation should make use of the patient’s idiosyncratic meanings, relate to their particular difficulties, use suitable metaphors and clearly establish the patient’s understanding and engagement with the planned interventions.

An explicit conceptualisation made clear by the therapist and is understood by the patient guides the therapy rationale and interventions.

All interventions should be related back to this overall conceptualisation and a clear rationale should be derived. This is particularly important when working on the trauma memory, for example with imaginal reliving. Therapists should be able to deliver a clear rationale for imaginal reliving/ writing a trauma narrative, which is convincing and uses concrete analogies from the patient’s range of experience. The rationale should be embedded within an overall PTSD conceptualisation as outlined above (trauma memory, appraisals, maintaining behaviours and cognitive strategies). The outcome of interventions should be linked back to the overall conceptualisation, which may need to be adapted or extended depending on the outcome.

Patients may express concerns and doubts about proposed interventions, and these need to be explored in detail by therapists. If patients express doubt about the trauma memory work, it is especially important that these are addressed prior to any work on the trauma memory. It is paramount that patients are given opportunity to feedback their reaction to the rationale, and that understanding of the specific treatment strategy is established.

N/A: Did not apply to this session (conceptualisation was developed in earlier sessions, and it appears from the session that patient and therapist share a common formulation and the patient understands rationale)

0 Therapist asked patient to do intervention without providing a rationale or linking it back to the overall conceptualisation

1 Therapist alluded too briefly to conceptualisation and gave a too brief, incomplete or very unclear rationale

2 Therapist gave incomplete conceptualisation and/or unclear rationale for procedures used. Some attempt to use a metaphor if appropriate. Major problems.

3 Therapist gave a rationale with satisfactory competence, embedded within an overall conceptualisation (using an appropriate metaphor if appropriate) but failed to check understanding or elicit feedback

4 Therapist gave a complete and clear rationale, clearly related to an overall PTSD conceptualisation, using appropriate metaphors if appropriate, checked for understanding and elicited some feedback. Minor problems

5 Therapist delivered a complete rationale tailored to the patient’s difficulties and idiosyncratic beliefs, closely related to an overall PTSD conceptualisation, use of appropriate metaphors if indicated. Checked for understanding, elicited feedback and dealt with questions and doubts effectively. Minimal problems

6 Therapist delivered an excellent rationale tailored to the patient’s idiosyncratic difficulties, established patient understanding and elicited and dealt with any doubts comprehensively. Used metaphors appropriately. Overall PTSD conceptualisation clearly guiding the intervention.

____ 11. RECLAIMING/REBUILDING YOUR LIFE

Many PTSD patients will have a sense that time has stood still since the trauma or a sense of permanent change. They are often no longer engaged in previously important activities (that they enjoyed or that gave them meaning) or no longer socialize with people that were important to them before the trauma. Others have been unable to rebuild new relationships, activities or vocational perspectives after significant loss. Each therapy session should contain some discussion of what patients will do to reclaim/ rebuild their lives, including a plan for reclaiming your life homework. This not only helps keep a focus on overall goals of therapy, but also helps them reconnect with the person they used to be before the trauma, and improve their level of activity, interpersonal functioning, and mood.

N/A: For intensive therapy or site visit day - reclaiming your life appropriately not covered in this session

0. Therapist did not address reclaiming your life in the session

1. Reclaiming your life was explored but in a cursory and unhelpful way and did not result in any plan for action.

2. Some discussion of reclaiming your life, but lacked consistency or clear rationale, or did not result in a satisfactory plan for action. Major problems evident

3. Reclaiming your life was addressed at a generally appropriate level with appropriate rationale, and linked to overall goals, and resulted in satisfactory assignments. Some inconsistencies in discussion or assignments set.

4. Good exploration of opportunities to reclaim life, linked to case formulation and treatment goals. Resulted in appropriate assignments tailored to individual goals of therapy. Minor difficulties.

5. Reclaiming your life addressed in session very competently, linked to case formulation and treatment goals, resulting in good assignments tailored to individual goals of therapy. Minimal problems

6. Excellent exploration of reclaiming your life with clear rationale, tailored to individual case formulation and goals. Excellent and realistic assignments tailored to individual goals of therapy with attention to detail.

____ 12 EDUCATION/NORMALISING

Education about common reactions during trauma and normalising of PTSD symptoms is a helpful basic therapeutic intervention in the treatment of PTSD. Information about common reactions and common responses can reduce feelings of shame and guilt, and normalising symptoms can counteract negative appraisals such as intrusive symptoms meaning to a patient that they are losing control. Information about common reactions to traumatic events and symptoms should thus be a major part of the initial stage of therapy, but can also form part of other therapy sessions.

Information/ education can be an important therapeutic tool in changing appraisals (e.g. that body has been permanently damaged) and perceptions the patient had at the time of the trauma (eg that car was likely to explode) and should be used when appropriate.

N/A Not relevant for this session

0 Therapist failed to explain nature of trauma reactions or normalise symptoms when indicated or failed to provide other corrective information that would have been appropriate

1 Therapist provided information / normalization in cursory or unhelpful fashion.

2 Therapist provided information / normalization but lacked consistency and used inappropriate examples. Major problems

3 Satisfactory competence in explaining trauma reactions and normalising symptoms or providing other relevant information, but some difficulties evident (eg too brief, difficult to understand, non-idiosyncratic, lacks confidence)

4 Therapist explained reactions and normalised symptoms or provided other relevant information well, with competent use of appropriate examples. Minor problems

5 Therapist explained trauma reactions and normalised symptoms or provided other relevant information with competence and confidence, skilfully as they arose in the session using idiosyncratic examples

6 Therapist delivered excellent explanation on trauma reactions and normalised symptoms, provided other relevant information skilfully, weaving it into guided discovery with idiosyncratic examples

____ 13 WORKING ON THE TRAUMA MEMORY or TRIGGERS OF INTRUSIONS

Trauma memory work forms an integral part of most PTSD therapy sessions, at least in the initial sessions. This can involve eliciting a brief account of the trauma, imaginal reliving, working with ‘hot spots’(worst moments), writing a narrative, restructuring and updating the trauma memory (reliving or narrative), discrimination of intrusive triggers, work on 'then' versus 'now', and revisiting the site of the trauma.

When working on the trauma memory, the session should include a rationale for the intervention used (or refer back to it), checking understanding and allowing time for questions, feedback, doubts and concerns.

Work on the trauma memory (whether reliving or narrative writing) should be closely interwoven with work on the problematic meanings that arise from the trauma (eg eliciting meaning of worst moments, exploring images, sensations and corresponding emotions and bodily reactions linked to the worst moments, linking new insights from discussion with worst moments in memory by "updating" procedures). Therapists should be able to demonstrate understanding of their client’s idiosyncratic problematic beliefs, related emotion and behaviours, and skill in setting up and delivering the chosen intervention.

The therapist needs to keep track of how well patients access the trauma memory by closely attending to the patient's responses during the memory work, and by eliciting ratings of distress and nowness (and possibly vividness).

There should be a clear underlying principle of elaboration of the trauma memory guiding the session. Therapists need to be able to sensitively adjust procedures for maximum benefit to the patient.

For stimulus discrimination sessions, there is less emphasis on problematic meanings. Instead, therapist and patient engage in detective work to identify idiosyncratic sensory triggers of intrusive reexperiencing (including affect without recollection) and on discriminating these from the triggers that were present during the trauma ("then" versus "now").

For site visits, the emphasis can vary between checking out particular predictions about the course of the trauma (eg how it could have been prevented), or on taking in the difference between the "then" versus "now".

N/A: Therapy session appropriately did not include work on trauma memory

0 Therapist failed to address trauma memory although this would have been necessary to deal with the problems the patient brought up

1 Inappropriate or unhelpful use of trauma memory techniques or failure to adequately implement them in the session, e.g., therapist discusses the trauma memory in a cursory fashion and in general terms which doesn’t lead to any key intervention or therapeutic work in the session; therapist pushes patient to do reliving although patient has expressed serious concerns, work on triggers focuses exclusively on meaning triggers

2 Some attempt at working on the memory in session but major problems evident, e.g., therapist failed to draw out idiosyncratic beliefs after reliving or narrative, failed to facilitate 'then' versus 'now' discrimination, misjudged level of engagement with trauma memory or handled high affect/ dissociation poorly.

3 Therapist worked on trauma memory generally competently, using a rationale for interventions, eliciting idiosyncratic meanings and related emotions if appropriate. Some difficulties (eg did not check for understanding, did not allow questions, did not elicit belief ratings, did not deal effectively with distress and emotion, missed possible sensory triggers or hot spots).

4 Therapist worked on the trauma memory competently, eliciting and discussing specific idiosyncratic beliefs/ or sensory triggers of intrusions or facilitating the reconstruction of what happened. Use of a plausible rationale for interventions, some feedback and discussion. Minor problems evident such as therapist failed to obtain clear feedback re impact of intervention/belief ratings and change.

5 Therapist worked on trauma memory skilfully using appropriate rationale for interventions, eliciting and discussing specific idiosyncratic beliefs/ or sensory triggers of intrusions or facilitating the reconstruction of what happened. Dealt effectively with level of distress and allowed time for feedback and discussion. Minimal problems.

6 Excellent work on the trauma memory, very skilful use of rationale and interventions, skilfully reconstructing trauma, eliciting idiosyncratic beliefs or identifying of sensory triggers. Dealt excellently with level of distress, facilitated cognitive and emotional change.

____ 14 MODIFYING NEGATIVE APPRAISALS

Cognitive therapy for PTSD concentrates on problematic appraisals of the trauma and its aftermath. As much of the patient’s evidence for the appraisals stem from the trauma memory, the discussion of appraisals should be closely integrated with the trauma memory work. Therapist should work with the patient to make the problematic appraisals explicit and concrete, and obtain belief ratings. Therapy should focus on identifying the patient’s evidence for the appraisal followed by a detailed discussion of evidence for and against. Ideally the discussion will result in some predictions derived from the discussion that can be further tested (through behavioural experiments, surveys etc). Therapist stance throughout is one of gentle enquiry, guided discovery and empathy. Common themes identified may be over-generalized sense of danger, inflated sense of responsibility, perceived guilt over what did or did not happen, feelings of humiliation, or pre-occupation with justice and unfairness.

N/A: The focus of the session was on other work where appraisals were not central (eg stimulus discrimination session)

0 Therapist failed to elicit PTSD cognitions/negative appraisals of the trauma.

1 Therapist explored PTSD appraisals on an abstract and general level with little focus on specific cognitions or the cognitions that were elicited did not explain patient's sense of threat/ emotions. Limited skill evident.

2 Therapist elicits PTSD cognitions/negative appraisals but major difficulties present ie cognitions selected were not central to patient's sense of threat/ emotions, selects inappropriate technique for cognitive change, didactic and inflexible in style

3 Therapist elicits PTSD cognitions/negative appraisals in a generally competent way and selects appropriate technique for cognitive change. Some problems evident (ie intervention is incomplete, patient understanding unclear, belief ratings omitted)

4 Therapist elicits key PTSD cognitions/negative appraisals and applies appropriate technique, with skill and flexibility. Minor problems evident.

5 Therapist elicits key PTSD cognitions/negative appraisals with skill and flexibility, applies change techniques comprehensively, change is monitored. Only minimal problems.

6 Therapist skilfully elicits key PTSD cognitions/negative appraisals, and applies excellent and highly appropriate techniques for cognitive change. Change is monitored.

____ 15 WORKING ON STRATEGIES THAT PATIENT USES TO CONTROL THREAT OR SYMPTOMS (COGNITIVE AND BEHAVIOURAL)

Maintaining behavioural and cognitive strategies prevent memory elaboration, exacerbate symptoms or hinder reassessment of problematic appraisals, and thus need to be dropped. The therapist’s role is to guide the patient to realise that safety behaviours and hypervigilance maintain a sense of threat and to decide to drop them in behavioural experiments. Other common examples of maintaining behaviours are thought suppression, rumination, avoidance of reminders, social withdrawal, use of substances to numb feelings and maladaptive efforts to control nightmares by going to bed late. A variety of techniques can be utilised such as cost-benefit analysis, worry chair technique, pie charts, work on probability, behavioural experiments in and out of the session, work on specific avoidance, re-visiting the site, activity scheduling, reclaiming your life. Work on maintaining behaviours/ cognitive strategies should always tie closely into the related PTSD cognitions and negative appraisals being activated.

N/A Focus of the session was on other issues

0 Therapist failed to identify maintaining behaviours/ cognitive strategies although pattern of appraisals and /or symptoms suggested that therapist should have addressed these.

1 Therapist explored maintaining processes on an abstract and general level with little focus on specific processes (ie hypervigilance, safety behaviours ….)

2 Therapist elicited PTSD maintaining behaviours/ cognitive strategies but difficulties present ie selected inappropriate technique for change, didactic and inflexible in style. No evidence of appropriate behavioural experiments or experiential exercise.

3 Therapist elicited PTSD maintaining behaviours/ cognitive strategies in generally competent way and selected appropriate technique for change. Some problems evident (ie intervention is incomplete, patient understanding unclear, belief ratings omitted)

4 Therapist elicited key PTSD maintaining behaviours/ cognitive strategies and applied appropriate technique which leads to change with skill and flexibility. Minor problems evident.

5 Therapist elicited key PTSD maintaining behaviours/ cognitive strategies with skill and flexibility, applied change techniques comprehensively, facilitating patient's dropping maintaining behaviours/ cognitive strategies. Change was monitored.

6 Therapist very skilfully elicited key PTSD maintaining behaviours/ cognitive strategies, and applied highly appropriate techniques for cognitive and behavioural change. Change was monitored.

______16 FOCUS ON APPROPRIATE ISSUES/ SESSION TARGETS AND SELECTION OF THERAPEUTIC STRATEGIES

0 Therapist did not select any appropriate techniques for changing PTSD related cognitions and maintaining factors

1 Therapist focused on inappropriate issues or techniques for change

2 Therapist selected specific techniques for cognitive change. However, the overall therapeutic strategy seemed vague and inappropriate for the stage in therapy. Problems may include choice of inappropriate issue to work on for this stage of therapy or choice of inappropriate or unhelpful techniques. Major problems

3 Therapist selected appropriate issues to work on and specific techniques for cognitive change but some problems and inconsistencies

4 Therapist seemed to have a generally coherent therapeutic strategy, which showed reasonable promise. This included focus on appropriate issues and choice of adequate techniques for facilitating cognitive change. Minor problems

5 Therapist followed a coherent, consistent therapeutic strategy, which seemed very promising. This included focus on appropriate issues and choice of adequate techniques for facilitating cognitive change.

6 Therapist identified key issues, followed a highly appropriate therapeutic strategy and made excellent choice of techniques to bring about cognitive change

OVERALL RATINGS AND COMMENTS

How would you rate the clinician overall in this session as a therapist using cognitive therapy for PTSD? (Ratings of 4 and above would indicate suitability as a therapist on a controlled trial for CT in PTSD).

0 1 2 3 4 5 6

Poor Barely mediocre satisfactory good v. good excellent

How difficult did you feel this patient was to work with?

0 1 2 3 4 5 6

Not Moderately Extremely

Difficult difficult difficult

Reasons/comment:

COMMENTS AND SUGGESTIONS FOR THE THERAPIST’S IMPROVEMENT:

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