The Cognitive Therapy Adherence and Competence Scale (CTACS)

This is an observer-rated scale consisting of 25 items addressing CBT processes or interventions such as homework and guided discovery. Each item is rated simultaneously for both adherence (scale ranging from 0 “none” to 6 “thorough”) and competence (scale ranging from 0 “poor” to 6 “excellent”) (Barber et al., 2003). For competence assessment, additional descriptions are provided for even numbers (i.e., 0 “the therapist seems unaware of the patients agenda” and 6 “the therapist set an excellent agenda…”).The scale is divided into four domains consisting of CBT structure, development of a collaborative therapeutic relationship, development and application of the case conceptualization, and cognitive and behavioral techniques. There is also a separate assessment for the client's degree of difficulty (one item). In CTACS, adherence is described as the degree to which the therapist engages in the process or intervention. Competence has been equated with quality and appropriateness and described as how well the intervention or process was performed. As described in the introduction, it has been proven difficult to separate adherence and competence empirically (Barber et al., 2003). In our dataset, the correlation between the mean adherence score and the mean competence score was also very strong (r = 0.97), suggesting lack of divergent validity. Results of the present study were therefore based on the competence items only. Adequate fidelity was defined as a mean CTACS score >3.0 (Haug et al., 2016). Two items evaluated as not applicable in the PMHC context were excluded; item 17 (“Eliciting core beliefs and schemas”) and item 20 (“Case conceptualization: Linking past to present”).