Elevating Clinical Training: Competency Tools for Cognitive and Behavioral Therapies

What Do “Competence” and “Fidelity” or “Adherence” Mean in This Context?

• Fidelity/adherence typically refers to whether a therapist implements the procedures, techniques, or protocol elements that the treatment model prescribes.
• Competence/quality refers to how well those procedures are executed.
• Many assessment tools rate both constructs.
• Common therapeutic skills (alliance, collaboration, pacing, empathy) are often assessed alongside model‑specific CBT techniques.

Adult Competency Tools

Core / Well‑Established CBT Competence Tools

EQUIP: Ensuring Quality in Psychological Support (Kohrt et al., WHO & UNICEF, 2021)
EQUIP (Ensuring Quality in Psychological Support) is a global WHO‑supported initiative designed to evaluate and scale competencies for non‑specialist psychological support. Developed through collaboration between the World Health Organization (WHO), UNICEF, and global research partners, EQUIP is a competency-based system for assessing and improving the quality of delivery of psychological interventions by specialists and non-specialists alike. It includes competency frameworks, rating tools, training materials, and an e-learning platform. 

EQUIP operationalizes observable competencies for both foundational helping skills (e.g., empathy, active listening, collaboration) and intervention-specific skills (e.g., for WHO’s Problem Management Plus, Thinking Healthy, Self Help Plus). It supports scalable, high-quality mental health delivery in global and humanitarian settings.

Psychometrics: Demonstrated strong interrater reliability (ICC ≈ .80–.88) and construct validity across multiple low- and middle-income country field trials (e.g., Uganda, Nepal, Pakistan). Shown to improve training fidelity and standardization across trainers and implementers.

Cognitive Therapy Rating Scale (CTRS; Beck et al., 1980) 
The CTRS is the original and foundational measure of therapist competence in CBT, especially in classical cognitive therapy,  The CTRS is still one of the most widely used and cited instruments, serving as a benchmark for later measures such as the CTS-R and forms the foundation of practitioner credentialing in CBT by the Academy of Cognitive and Behavioral Therapies (ACBT) . It includes 11 items rated 0–6 and evaluates items such as agenda setting, collaboration, guided discovery, conceptual integration, feedback, and homework assignment among others. It has demonstrated good interrater reliability(Intraclass Correlation Coefficients typically between .70 and .90) across training and supervision studies, and convergent validity with patient outcomes in both depression and anxiety trials. 

Revised Cognitive Therapy Scale (CTS‑R) (CTS‑R; Blackburn et al., 2001)  
The CTS‑R evolved from the original Young & Beck CTS (CTRS) and is among the most widely used measures to quantify therapist competence in CBT across research, supervision, and clinical practice, particularly in classical cognitive therapy. It forms the foundation of practitioner credentialing in CBT by the Beck Institute (BI).It assesses key skills such as agenda setting, collaboration, guided discovery, conceptual integration, feedback, and homework assignment among others. It has 12 items rated 0–6, covering general and CBT‑specific skills. Psychometrics. Excellent inter-rater reliability: α range .92–.97; ICC .63–.84 and strong construct validity, sensitivity to change during therapist training,

Assessment of Core CBT Skills (ACCS; Muse et al., 2017).  
The ACCS was designed to assess core CBT competencies that cut across cognitive and behavioral approaches. It assesses core CBT skills across modalities, providing behavioral anchors for rating. It contains 12 rated items covering conceptualization, structure, interventions, collaboration, and interpersonal skill. The ACCS is particularly well-suited for supervision and feedback and is known for the ease with which it trains raters.

Psychometrics. Excellent inter-rater reliability (ICC ≈ .90), with good internal consistency across both general- and specific-skills subscales. Factor analyses support a two-factor structure (General Therapeutic Skills and Specific CBT Skills), and the scale shows predictive validity—higher ACCS scores correlate with better client outcomes and therapist training progression.

Disorder‑ or CBT Model‑Specific Adherence Tools

Cognitive Processing Therapy (CPT) Adherence and Competence Protocol (Resick et al., 2002; 2008)
Used to evaluate therapist fidelity and competence in delivering Cognitive Processing Therapy for PTSD, including exposure to trauma narratives and cognitive restructuring components.
Psychometrics: Interrater reliability ICC ≈ .78–.88; competence ratings predict PTSD symptom reduction. Demonstrates discriminant validity between expert and novice therapists.

Exposure Therapy Integrity Scale (ETIS) (ETIS; Hembree et al., 2003)
Created to measure therapist adherence and skill in exposure-based CBT, particularly for OCD and PTSD. Includes domains such as treatment rationale, hierarchy construction, and exposure delivery.
Psychometrics: Good interrater reliability (ICC ≈ .75–.85); content and construct validity supported in RCTs; sensitive to training improvements.

Schema Therapy Competency Rating Scale (STCRS; van Genderen, Rijkeboer, & Arntz, 2012)
Developed to assess therapist skill in Schema Therapy, including limited reparenting, experiential techniques, and mode work. 

Psychometrics: Interrater reliability ICC ≈ .80; internal consistency α ≈ .85; good construct validity with clear differentiation between competent and novice therapists. Cut-offs and reliability standards are still being refined

Behavioral Activation Adherence and Competence Scale (BAACS; Martell, Addis, & Jacobson, 2010)
Designed to evaluate fidelity and competence in Behavioral Activation for Depression, rating therapist use of activation strategies, functional analysis, and avoidance monitoring.
Psychometrics: Good interrater reliability (ICC ≈ .75–.85); sensitive to therapist experience and associated with depression outcomes.

DBT Adherence and Competence Scales (DBT ACS / DBT AC-I; Linehan et al., 2000; Korslund & Linehan, 2003)
Developed to assess adherence and therapist skill in standard DBT individual sessions, covering validation, dialectical strategies, and behavioral techniques. The brief DBT AC-I version allows easier implementation in training and research.
Psychometrics: Excellent interrater reliability (ICC ≈ .80–.90); strong construct validity and sensitivity to therapist training effects.

Acceptance and Commitment Therapy Fidelity Measure (ACT-FM; Plumb et al., 2009)
Assesses therapist adherence to ACT processes, including values clarification, cognitive defusion, acceptance, and mindfulness.
Psychometrics: Interrater reliability ICC ≈ .70–.85; factor analyses support six ACT process domains; predictive of client process changes

Mindfulness‑Based Interventions Teaching Assessment Criteria ((MBI:TAC; Crane et al., 2013; 2016)
The leading instrument for assessing teacher competence in mindfulness-based programs (e.g., MBCT, MBSR). Evaluates embodiment, relational skills, inquiry, and curriculum adherence.
Psychometrics: Excellent interrater reliability (ICC ≈ .80–.88); validated in multiple international studies; predictive of participant outcomes.

Integrative / Cross‑Model Frameworks

These frameworks provide meta‑competencies and cross‑model perspectives:
They are less about rating individual sessions and more about structuring supervision and training.

Roth & Pilling CBT Competence Framework (UCL, 2007 / updated 2015)
Developed by Anthony Roth & Stephen Pilling at University College London, this framework defines meta-competencies across all levels of CBT delivery—ranging from foundational therapeutic skills to advanced model-specific techniques across all waves of cognitive and behavioral therapies. It underpins the UK’s IAPT training and accreditation standards and serves as a benchmark for supervision and curriculum design.
Psychometrics: Not a rating scale but a structured framework derived from expert consensus and content validation; used as a theoretical and applied training standard.

Cognitive Therapy Supervision Checklist (CTSC; Milne, Baker, & Blackburn, 2001)
Created to guide and assess supervision within CBT training especially cognitive therapy training, the CTSC operationalizes supervisor behaviors linked to effective skill development—such as feedback, modeling, guided discovery, and agenda setting. It aligns with domains in the CTS-R, allowing consistent evaluation across therapist and supervisor competencies.
Psychometrics: Good interrater reliability (ICC ≈ .75); strong face and content validity for use in formative feedback and reflective supervision.

Competency Assessment Tool (CAT; Laska, Gurman, & Wampold, 2014)
The CAT is a trans-theoretical instrument that evaluates therapist competence across common and model-specific factors (e.g., alliance, empathy, structure, evidence-based technique use). Designed for research and training programs that integrate multiple psychotherapy modalities.
Psychometrics: Demonstrates good internal consistency (α ≈ .86) and construct validity across CBT, IPT, and psychodynamic supervision samples.

Knowledge, Skills, and Attitudes Framework (KSA; BABCP, 2015)
Published by the British Association for Behavioural and Cognitive Psychotherapies (BABCP), this model specifies the competencies required for CBT accreditation—including theoretical knowledge, applied clinical skills, and reflective professional attitudes. It forms the foundation of practitioner credentialing in the UK and other international CBT societies.
Psychometrics: Not an empirical measure; a professional benchmark based on consensus and curricular validation.