Manual for the Cognitive Therapy Rating Scale for Children and Adolescents

Manual for the Cognitive Therapy Rating Scale for Children and

Adolescents (CTRS-CA)

Robert D. Friedberg, Ph.D., ABPP, ACT

Center for the Study and Treatment of Anxious Youth at Palo

Alto University

September 2014

A. General Stance Variables

1. Collaboration (See also CTRS manual, Young & Beck, 1980)

Rationale: A collaborative relationship is one built by consensus rather than unilaterally

imposed by either the therapist, youth, or family member. Collaboration refers to a team

approach to problems. Creed and Kendall (2005) found the collaboration between young

patients and their therapists predicted a strong working alliance. More specifically, Peterman et

al. 2014b noted that collaboration decreases attrition. It is a well-worn axiom that young patients

learn more if change comes from their own thoughts, feelings, and actions. Collaboration

emphasizes that therapy is done with young patients than prescriptively applied to them.

Appropriate self-disclosure is often a strategy to enhance collaboration with young patients.

Frequent check ins with patients facilitate collaboration

Background resources

Cognitive Therapy and Emotional Disorders (pp. 220-221)

Cognitive Therapy for Depression (pp. 50-54)

CBT for the busy child psychiatrist (pp. 45-46).

Clinical practice of cognitive therapy with children and adolescents (pp. 34-44)

Newman (1994)

Desirable Therapist Strategies

1. Level of collaboration is titrated to

a. Stage of therapy

b. Nature of the presenting problem

c. Developmental level

d. Childs Interpersonal style. Variables such as characteristic passivity,

submissiveness, controllingness, need for dominance, etc will influence young

patients responsiveness to collaboration. Good cognitive behavioral therapists are

alert to these vicissitudes.

e. Cultural context. Cultural values and ethics such as deference to authority,

interdependence, equalitarianism, obedience to authority, etc will shape patients

and families level of collaboration. Good ratings on this dimension appreciate

cultural responsiveness.

2. Provides choices and options

a. What would you like to happen?

b. What would you like to do?

c. We are kind of stuck, what ideas do you have to move us forward?

3. Asks for permission

a. How willing are you to ___?

b. May I ask you a difficult question?

4. Uses frequent check ins

a. How does that sound to you?

2. INFORMALITY

Rationale; Children and adolescents respond well to informal therapists (Creed & Kendall,

2005). Optimally, the therapist balances an authoritative, adult stance with an informal demeanor

when interacting with young patients. Clearly, clinicians want to avoid talking down to children

and talking to them in baby-talk like tones. Informality should not be confused with indulgence

or the absence of therapeutic limit setting. Neither should it be confused with a sense that CT is

not a serious undertaking.

However, good CBT therapists avoid a pompous, stuffy stance that is overly parental. The key is

create a relaxed therapeutic milieu where children are sufficiently comfortable to approach their

problems flexibly and experiment with new thought, feeling, and action patterns. Ideally, the

therapist is able to directly communicate a sense of genuine appreciation of the young patients

and their family members perspectives. Where limits are indicated, they are imposed

authoritatively rather than in an authoritarian manner. The therapist is also adept at

communicating his/her enjoyment in taking care of the patient and their collaborative work.

While informality may include play with younger children, good cognitive therapists may

achieve informality through discussions of hobbies, interests, and peer activities with adolescents

as well as judicious self-disclosure.

Background material:

CBT for the busy child psychiatrist (pp.58-60)

Creed & Kendall (2005)

Desirable Therapist Behaviors

1. Appreciates cultural context. Cultures vary in their appreciation of informality. Some

culture subgroups highly value formality and restraint whereas other weigh

informality more heavily.

2. Adopts a transparent, empirical stance.

3. Engages in appropriate therapeutic use of self-disclosure

4. Talks with child and parent in a developmentally sensitive, plain manner without

confusing jargon and vocabulary

5. Interpersonal tone is free of preachiness, stuffiness, and condescension.

6. Acts friendly and without an inaccessible professional demeanor

7. Sets limits in a warm and authoritative manner

3. Playfulness

Rationale: CBT is hard work but it does not have to be unpleasant (Friedberg et al., 2011,

Peterman et al. 2014a). Playfulness and fun enlists young patients in the therapeutic enterprise.

Fun enjoys a long-standing tradition in CBT spectrum approaches (Chu & Kendall, 2009;

Stallard, 2005; Stallard et al. 2014 ). Playfulness decreases childrens perception that CBT is

boring and dull. Moreover, playfulness fits well into the experiential nature of CBT. Playfulness

humanizes and normalizes psychotherapy (Wright et al. 2006, p. 34). Moreover, Borcherdt

(2002) noted that playfulness increases transparency, emotional tolerance, energy, and

therapeutic investment. Further, playfulness requires developmental sensitivity. Sburlati et al

(2011) noted that playfulness, creativity, and informality are developmental accomodations.

Adding fun and playfulness in session augments the reinforcement value of the therapeutic work.

Playfulness is key to making CBT real and relevant to young patients lives (Peterman et al.,

2014a, 2014b). While CBT is serious work that deals with sobering issues, CBT with children

and adolescents does not have to be applied in a heavy handed manner. Indeed, inaccurate beliefs

can be captured and modified in playful ways. Stories, rewards, games, metaphors, drawing,

music, and theatre exercises are used in playful CBT (Friedberg & McClure, 2002; Friedberg et

al. 2011; Peterman et al. 2014a, 2014b). However, playfulness with older children may include

verbal repartee and humor.

Background material

Clinical practice of cognitive therapy with children and adolescents (pp. 146-166).

Cognitive behavioral therapy for the busy child psychiatrist (pp. 58-60).

Peterman et al. 2014a; Peterman et al. 2014b

Desirable Therapist strategies

1. Creates a pleasant treatment milieu yet earnestly communicates the seriousness of

clinical work

2. Inspires a sense of curiosity in young patients by use of engaging, fun, and lively

experiential activities to identify as well as modify unproductive thought, feeling, and

action patterns.

3. Uses developmentally and culturally appropriate metaphors, games, stories, drawing,

music, games, theatre exercises, etc. to identify and modify unproductive thought,

feeling, and action patterns.

4. When indicated, administers contingent rewards to reinforce young patients

behavior.

4. CREDIBILITY

Rationale: The credibility domain is consistent with Shirk and Karvers (2006, p. 480) notion

that the clients experience of the therapist as someone who can be counted upon for help in

overcoming problems or distress. Garcia and Weisz (2002) discovered that doubts about

clinicians competence, perceptions that the therapist was not clear in explaining treatment

rationale, and/or were not helpful were related to the patient-therapist relationship problems.

Effective limit setting also instills a sense of credibility in young patients and their families.

Credibility is reinforced by therapist behavior. It is essential that therapists demonstrate their

credibility rather than trying to persuade patients they are credible.


CBT for the busy psychiatrist (p.53)


1. Has an abundance of resources

2. Is fluent with state of the science on disorders and CBT treatment

3. Adopts a problem-solving stance to even the most difficult circumstance

4. Follows Through on commitments: Sessions begin and end on time, if resources are

promised to patient, clinician provides them.

5. Recalls and uses information reported by patients and their families.

6. Explains clinical issues and CBT in a clear simple manner free of jargon. When

appropriate, useful of metaphors makes the material more accessible.

a. Avoids use of psychobabble words such as defensiveness, externalization,

issues, etc.

b. Shares conceptualizations with patients

5. PACING AND PUSHING (see also Young and Beck, 1980)

Rationale: Pacing and pushing is a balancing act. Helping children and their families in most the

efficient manner is the goal. The key is to lessen distress in the most expedient yet enduring

manner. Treatment that unnecessarily prolongs relief is contraindicated. However, good

cognitive behavioral therapists balance pushing the child toward change and pacing sessions so

as not to overwhelm young patients. Maintaining an equilibrium between task and non-task

behaviors/topics in session is essential. Of course, focusing on salient issues is pivotal.

However, good cognitive therapists pace the session and give children breaks or rest periods

during their time together. In this way, the child is not flooded. Pacing and pushing skills include

setting limits in session, focusing patients on key issues, and redirecting unproductive, derailing

dialogues. Limit setting is reassuring to children and decreases ambiguity in session.


CBT for the Busy Child Psychiatrist (pp.51-53;

Cognitive Therapy of Depression (pp. 65-66)

Newman (1994)


1. Uses prefacing remarks such as Some boys and girls find this upsetting, I am

going to ask you a difficult question (Newman, 1994)

2. Gently persists when patients avoid (Newman, 1994).

a. I know this is hard and you want to change topics but lets try to hang in

there with this issue a little longer.

3. Avoids interrogating. Adheres to a hypothesis testing stance.

4. Gives young patients appropriate rest periods in session

6. INTERPERSONAL EFFECTIVENESS AND EMPATHIC COMMUNICATION: (see also Young & Beck, 1980).

Rationale: This domain is grounded in Brew and Kottlers (2008) stance that empathy requires

the observation of patients emotional arousal and the imagination necessary to communicate a

shared perspective. Simply, empathic cognitive behavioral therapists are successful in seeing the

world through childrens eyes. They are effective in grasping both the content of childrens inner

experiences and the context in which they occur. Additionally, good working relationships are

marked by interpersonal liking and emotional closeness (Creed & Kendall, 2005).

Interpersonally effective cognitive behavioral therapists communicate they genuine enjoy

treating young patients.

Empathic communication, like any other skill, has its appropriate use. Empathy amplifies

emotions so change can occur in the context of negative affective arousal. Empathic and

interpersonally effective therapists are alert to the subtleties and nuances in session. However,

despite their omnipotence, these skills represent necessary but not sufficient ingredients for

effective child psychotherapy.

Background material

Cognitive Therapy of Depression (pp. 45-47, 49-50)


1. Understanding is precisely communicated, parroting of patients verbalization is

avoided.

2. Empathic statements are meaningful. They are more stereotyped responses that could

apply to most anyone (e.g. That must be hard). In beginning therapists, empathic

statements tend to be stereotyped and platitudinous (e.g.). More advanced therapists

are facile in linking thoughts, feelings, and behaviors together to construct powerful

and individualized empathic communications ( I can see how difficult it is for you

when you think you are too dumb to do your work, you feel really sad, and then put

off your work).

3. Remembers and uses information provided by patient/family in session

B.SESSION STRUCTURE DOMAINS

1. AGENDA SETTING (See also Young & Beck, 1980)

Rationale: Agenda setting is a signature element in Becks Cognitive Therapy. Agenda setting is

a collaborative process where young patients, family members, and their therapists sketch out a

blueprint for the session. Agenda setting serves transparency and informed consent in every

session. Critical items are allocated time and therapeutic focus so the session is organized and

therapeutic momentum is realized. Agenda setting adds structure to patients inner lives. Agenda

setting is a therapy enhancing variable.


Cognitive Therapy of Depression (pp. 77-78, 93-98, 167-208)

Cognitive Therapy: Basics and beyond (Chapter 5)

Cognitive Therapy of the Emotional Disorders (pp. 224-300).

CBT for the Busy Psychiatrist (pp.72-74)

Clinical practice of CT with children and adolescents (pp. 54-58)

Desirable Therapist Strategies: The therapist should clearly introduce and explain agenda

setting at the initial session. Additionally, flexibility in setting agendas is also indicated.

Clinicians should also see agenda setting as both a procedure and a process.

1. Sets agenda in a clear and child friendly manner

a. What should we talk about today

b. What is on your mind today?

c. What is bugging you today?

d. What is bothering you today?

e. What should we focus on today?

f. How do you want to spend our time today?

g. What should we work on today?

h. What is it you want to make sure we talk about today?

i. What is it you want to make sure we cover before we end today?

2. Stays collaborative with agendas. Remember you will have items to put on the

agenda and a collaborative stance gives you the freedom to include your items on the

agenda as well.

3. Processes difficulties with agenda setting

a. Passive agenda setting. Good ways to address passive agenda setting

i. What goes through your mind when I ask you for agenda items?

ii. What is it like for you to for you to decide on what we focus on today?

iii. What do you guess might happen if you picked what we talked about

today?

b. Active avoidance of agenda setting

i. What is the bad thing about setting agendas?

ii. What do you guess it would mean about you if we set an agenda?

iii. What might you lose if you set an agenda?

c. Too many items on the agenda

i. What things are most important?

ii. What makes this a must for today?

iii. How much time should we spend on ___?

iv. What are the most important and least important things? What makes

them most and least important?

2. ELICITING FEEDBACK (see also Young & Beck, 1980)

Rationale: Eliciting feedback is yet another explicit therapeutic relationship enhancing process.

Feedback gives clinicians an explicit gauge about the way the patient thinks and feels about

therapy. Moreover, by properly eliciting feedback, the therapist can correct patients

misperceptions, clarify miscommunication between the therapist and patients as well as problem

solve obstacles in therapy. Receiving negative feedback is commonly uncomfortable and

unsettling Nonetheless, it is important to help the patient explicitly express their dissatisfactions

in session. Responding in a non-defensive and matter of fact problem solving way is

recommended and builds strong working relationships.


CBT for the busy child psychiatrist (pp. 80-82)

Clinical practice of cognitive therapy with children and adolescents (pp. 62-67)

Cognitive Therapy: Basics and Beyond (chapter 5)



1. Useful questions to elicit feedback

a. What was helpful/not helpful about our work today?

b. What seemed right about our session? What did not seem right?

c. What rubbed you the wrong way today? What made sense for you today?

d. What was satisfying for you today? What was not satisfying for you?

e. What is the take away message from todays session?

f. If todays meeting had a title, what would it be?

2. Useful questions to process reluctance to give feedback

a. What is like for you to give me feedback?

b. What do you guess will happen if you tell me your negative and positive

feedback?

c. How do you suppose I will see you if you give me positive or negative

feedback?

d. What are the pros and cons of giving me feedback?

3. Useful questions to process overly positive feedback

a. What do you guess would happen if you gave me negative feedback?

b. What rules might you break if you gave me negative feedback?

c. What would it mean about you if you gave me negative feedback

d. What would it mean about me if you gave me negative feedback

4. Useful questions to process overly negative feedback

a. What is it like to give an adult negative this type of feedback

b. What is it like for you to give an authority figure this type of feedback?

c. What made you see me as _____?

d. What surprises you about my reaction to your feedback?

3ASSIGNING AND PROCESSING HOMEWORK (see also Young & Beck, 1980)

Rationale: Homework is an indispensable way to generalize treatment gains to childrens natural

environments. Doing homework makes the abstract task of therapy concrete to young patients.

By assigning and reviewing homework in session, it becomes central to therapy. Finally, the

practice embedded in homework makes therapy less of a disposable commodity. Essential,

homework literally is a take-away product from the therapy session.



Clinical practice of Cognitive Therapy with Children and Adolescents (2nd ed), (pp 61-62;

Chapter 10) ,

CBT for the busy child psychiatrist (pp. 82-84),

Cognitive Therapy: Basics and beyond (Chapter 17)


1. When appropriate, considers calling homework something else (e.g. tool kit, STIC

tasks, challenges adventures, etc)

2. Ties Homework to Presenting problems

3. Applies a graduated approach

4. Begins homework in session

5. Processes the childrens reaction to the task

a. How helpful do you guess this homework will be?

b. How optimistic are you about the homework?

c. How much do you think this homework will make you feel better?

6. Follows up on homework assignments

7. Processes homework non-compliance. Uses guided discovery to assess

a. Understanding of the task

b. Appropriateness of the assignment

c. Patient lack of skill

d. Contextual parameters

e. Patients fear of failure

f. Patients fear of loss of control

g. Patients fear of discomfort

h. Patients fear of loss of approval

i. Patients fear of change

j. Patients fear of disclosure

k. Patients level of rebelliousness and opposition

C. STRATEGIES FOR CHANGE

1. GUIDED DISCOVERY: (see also Young & Beck, 1980)

Rationale: Guided discovery encourages young patients and families to build their own

data bases for rational analysis. GD is composed of a variety of elements including

empathy, socratic questions, and behavioral experiments. The goal of GD is to cast doubt

on beliefs and create a milieu of curiousity in session (Padesky, 1993). In guided

discovery, no answers are provided for patients. Rather, patients are taught to ask better

questions of themselves (Padesky, 1993). Indeed, guided discovery is the search for

possibilities. This in contrast to a style that supplies interpretations or insights for young

patients.



Clinical practice of cognitive therapy with children and adolescents (Chapters 3, 7)

Cognitive behavioral for the busy child psychiatrist (p. 47, Chapters 8, 9)

Cognitive Therapy: Basics and Beyond (pp. 23-25; Chapters 11,12)

Overholser (1993a,1993b, 1994, 1996, 2010)

Padesky (1993)

Rutter & Friedberg (1999)


1. Avoids Why Questions. Why questions prompt children to intellectualize and

sanitize their responses. Moreover, why questions contribute to children

rationalizing and defending their position. Finally, patients tend to perceive

why questions as implicit criticisms.

2. Focuses on stimulating cognitive dissonance (e.g. doubt) rather than refutation

and disputation

3. Uses guided discovery to add perspective and flexibility and not to trap young

patients. Takes a multi-sided view of beliefs

a. Line of questions

i. What do you do that a total loser would never do?

ii. What does a total loser do you would never do?

iii. How do other people in a total losers life treat them that

people in your life would never do?

4. Lays out the foundation for the childs inaccurate beliefs. The key here is that

the therapy allows an open guided discovery where the factual basis for the

childrens beliefs are not pre-empted.

a. What make you believe that ____?

b. What convinces you that _____?

5. Uses short, simple, open-ended questions especially with younger children.

a. How can you tell that _____?

b. In what ways, _____?

6. Varies the type of question asked. Adopts a flexible approach. Realizes that

not all questions have to phrased as a question (e.g Tell me about..)

(Overholser, 1993a)

7. Avoids presumption and assumption. Its OK not to know.

a. You keep saying I dont know. But there is so much going on inside

you. How can that be?

8. Engages in an organized coherent Guided Discovery process

9. Considers cultural contexts. Guided discovery is modified to fit patients

cultural contexts.

10. Demonstrates developmental sensitivity by including childrens idioms and

metaphors are ways to enhance the child-friendliness of the GD process.

2. FOCUSING ON KEY COGNITIONS (See also Beck & Young, 1980)

Rationale: As Young and Beck (1980) aptly noted, this domain reflects therapists

skillfulness in crafting and implementing an individualized case conceptualization. When

therapists accurately focus on key cognitions, therapeutic effectiveness and efficiency are

served. Psychotherapy is a centered rather than a rambling process. By identifying and

working with hot cognitions, good CBT therapists maximize the emotional saliency of

sessions.


Cognitive therapy for the emotional disorders, 6-131,

Cognitive Therapy for Depression, pp. 142-152, 163, 244-252

Clinical practice of cognitive therapy with children and adolescents (Chapters 2, 6, 7)

CBT for the busy psychiatrist (Chapters 2, 8, 9)

Cognitive Therapy: Basics and beyond (Chapters 2, 9, 10)


1. Use of classic cognitive therapy question and its variants at the moment of

mood shifts in session (e.g. What is going through your mind, right now?)

2. Mindfully considers of the content-specificity hypothesis

Mood state Cognitive Content

Depression Negative view of the self

Negative view of others/ones experience

Negative view of the future

Anger Hostile attributional bias

Confusing deliberate with accidental

Labelling the other person

Sense of unfairness

Violation of personal rules and

imperatives

Anxiety Overestimation of the probability of

the danger

Overestimation of the magnitude of

the danger

Ignore coping resources

Neglect of rescue factors

Panic

Catastrophic misinterpretation of

normal bodily sensations

Social Anxiety Fear of negative evaluation

3. Employs laddering to elicit hot thoughts. Uses the content-specificity

hypothesis to guide questions in laddering processes.

4. Asks one question at a time

5. Eliminates cognition hopping. According to Padesky (1988), cognition

hopping is the therapists tendency to jump from one thought to another in a

knee-jerk, random way without settling on a core cognition. Relying on the

Content-Specificity hypothesis and a case conceptualization prevents

cognition hopping

6. Reduces superlative work with superficial cognitions. According to Padesky

(1988), clinicians are well advised to save techniques for emotionally salient

thoughts. Do CBT with meaningful cognitions rather than ones that are only

peripherally tied to emotions or loosely linked to the case conceptualization.

Once again, attention to the content specificity hypothesis and case

conceptualization works against this error.

3. STRATEGY FOR CHANGE (see also Young & Beck, 1980)

Rationale: Similar to Focusing on Key Cognitions, this domain explicitly addresses the

application of case conceptualization to guide treatment delivery. Shirk (1999) warned

that applying CBT without a strategy is like mixing ingredients together without a recipe

As Young and Beck (1980) stated, there are many available methods and procedures.

Case conceptualization guides the systematic selection and timing of interventions.

Moreover, case formulation customizes interventions.

In the CTRS manual, Young and Beck (1980) wrote that although inferring case

conceptualization from listening or watching a session is challenging, if the therapist is

skillful, the rationale for interventions should be readily discernible. Indeed, the case

conceptualization transparently reflects the therapists mental infrastructure and fosters

an organized, mindful, deliberate treatment delivery package. The intervention strategy is

coherent rather than fragmented. As Young and Beck (1980) taught interventions hang

together in a unified framework.


Cognitive Therapy and the emotional disorders (pp.233-300)

Cognitive Therapy of Depression (pp.104-271)

Clinical practice of cognitive therapy with children and adolescents (Chapter 2)

CBT for the busy psychiatrist (Chapter 2)

Cognitive Therapy: Basics and beyond (Chapters 2, 19)


1. Avoids a Bag of tricks approach. Focuses on a central issue rather than

chasing separate fires.

2. Applies the method to the proper treatment target (e.g. exposure/experiments

used to decrease avoidance, pleasant activity schedule used to activate patient,

etc).

3. Techniques and procedures do not come out of the blue. Instead, they are

seamlessly connected to session content and are customized to individual

patients presentation/complaints.

4. APPLICATION OF COGNITIVE BEHAVIORAL TECHNIQUES ( See also

Young & Beck, 1980).

Rationale: This domain explicitly deals with therapists technical proficiency. Technical

proficiency reflects the proper use and implementation of specific procedures listed below. Good

CBT clinicians apply an effective dose when they use the procedures skillfully according to

stipulated guidelines and rubrics. Kendall and colleagues maxim of flexibility within fidelity is

especially apt here. Indeed, therapists need to respond to moment-to-moment interactions with

patients (Beidas et al. 2010). Practicing flexibility within fidelity allows customizing treatment

to individual without suffering theoretical drift.

Background material

Cognitive Therapy of Depression (pp. 27-32, 67-72, 104-271, 296-298)

Cognitive Therapy of Emotional Disorders ((pp.221-225, 229-232, 250-254, 282-299)

Clinical practice of cognitive therapy with children and adolescents (Chapters 8, 9,

11,12,13, 14)

CBT for the busy psychiatrist (pp. Chapters 5-10)

Cognitive therapy techniques for children and adolescents (Chapters 3-7).

Cognitive Therapy: Basics and Beyond (Chapters 6, 15, 16)


1. Use of Modular Techniques

Psychoeducation

Self-Monitoring

Basic Behavioral Tasks

Pleasant Activity Scheduling/Behavioral Activation

Mastery and Pleasure Ratings

Relaxation

Social Skills

Contingency Contracting

Cognitive Interventions

Self-instruction

Problem-solving

Advantages and Disadvantages

Test of Evidence

Reattribution

Decatastrophizing

Universal Definitions

Continuum

Imagery

Experiments and Exposures

2. Applies these techniques in session so experiential learning is optimized

3. When indicated, Techniques are applied flexibly and creatively yet faithfull

adhere to fundamental principles and guidelines

Scoring:

The CTRS-CA is rated on a 7 point scale ranging from 0-6. A score of 6 should be reserved for

EXPERT level. 4 is the expected score for COMPETENT CBT practice and most skillful CBT

therapists will most likely achieve this level.

0- Therapist behavior indicating skill in this domain is ABSENT or NEARLY ABSENT as

defined in the item anchors and manual. Many major and minor flaws in implementation

are evident.

1- Therapist behavior indicating skill in this domain is MINIMALLY PRESENT as defined

in the item anchors and manual. Minor and major flaws in implementation are obvious.

2- Therapist behavior indicating skill level in this domain is INCONSISTENTLY APPLIED and/or CONSISTENTLY BELOW A BASIC LEVEL of practice defined

by the item anchors and manual. Several minor and major flaws in implementation are

obvious.

3- Therapist behavior indicating skill at a BASIC level. The behaviors defined in the item

anchors and the manual are applied more often than not and with moderate proficiency.

Several minor flaws and some major flaws in implementation are evident.

4- Therapist behavior indicating skill at a COMPETENT level. The behaviors defined in

the item anchors and the manual are applied quite frequently and with very good

proficiency. Only a few minor or major falwss in implementation are evident

5- Therapist behavior indicating skill at EXCELLENT level of COMPETENCY. No major

flaws and only some minor flaws in implementation are evident.

6- Therapist behavior indicating skill at an EXPERT level. The behaviors defined in the item anchors and the manual are completely present throughout the session and applied

with EXCEPTIONAL COMPETENCY. Nearly flawless work in session.

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Documents

Manual for the Cognitive Therapy Rating Scale for Children and Adolescents