Cognitive Behavioral Therapy: A Blueprint for

Attaining and Assessing Psychiatry Resident

Competency

Donna M. Sudak, M.D.

Judith S. Beck, Ph.D.
Jesse Wright, M.D., Ph.D.

Background: The Residency Review Committee (RRC) for Psychiatry of the Accredita-
tion Council on Graduate Medical Education (ACGME) now requires that all psychiatric
residency programs demonstrate competency for all psychiatric residents in cognitive be-
havior therapy (CBT). Objective: To increase awareness about specific knowledge, skills,
and attitudes necessary to perform competent CBT, optimal teaching methods available to
insure competency, and valid assessment tools and resources available to training pro-
grams. Methods: Literature review and discussion of common features of successful
training programs. Results and Conclusions: Training programs have resources and
standardized methods of training, supervision, and assessment available to help residents
meet the ACGME mandated competency requirements in CBT. (Academic Psychiatry
2003; 27:154–159)

C ognitive behavioral therapy (CBT) is a form of

psychological treatment with a comprehensive
theory of psychopathology and personality and spe-
cific models for various disorders. The therapy re-
quires an empathic, active clinician, who collaborates
with patients in order to define specific treatment
goals. Sessions are structured with the purpose of re-
Disclosure Statement: Jesse H. Wright may receive royalties
from the sale of the DVD-ROM computer program described in
this article.
Dr. Sudak is Associate Professor, Department of Psychiatry,
Drexel University College of Medicine, Philadelphia, Pennsylva-
nia. Dr. Beck is Clinical Associate Professor, Department of Psy-
chiatry, University of Pennsylvania, Philadelphia, Pennsylvania,
and Director of the Beck Institute for Cognitive Therapy and Re-
search, Bala Cynwyd, Pennsylvania. Dr. Wright is Professor and
Associate Chairman, Department of Psychiatry and Behavioral
Sciences, University of Louisville School of Medicine, Louisville,
Kentucky. Address correspondence to Dr. Sudak, Eastern Penn-
sylvania Psychiatric Institute, 3200 Henry Avenue, Philadelphia,
PA 19129, ds42@EXCHANGE1.DREXEL.EDU (E-mail).
Copyright 䉷 2003 Academic Psychiatry.
ducing symptoms and learning disorder-specific cog-
nitive and behavioral skills. Cognitive therapy has
been found to be effective in working with individ-
uals, groups, couples, and families (1).
Although CBT was initially developed as a treat-
ment for depression, it has been adapted for a wide
range of psychiatric disorders and continues to be
distinguished by substantial empirical support for its
effectiveness in more than 325 outcome trials (2,3).
This treatment approach has a long history of stan-
dardizing methods for therapist training, supervi-
sion, and assessment (4,5). Treatment manuals for the
use of CBT in major psychiatric disorders have been
developed, validated, and published (6–19).
The purpose of this article is to provide training
directors with the critical elements necessary for
teaching psychiatry residents about CBT, methods for
assessing the skills necessary to perform competent
CBT, and resources available for developing robust
CBT training programs for residents.

154 Academic Psychiatry, 27:3, Fall 2003


ESSENTIAL INGREDIENTS OF
COGNITIVE THERAPY
To obtain basic competency in cognitive therapy, res-
idents must be able to do the following:
1. Formulate cases according to the cognitive
model for various disorders
2. Develop a strong, active, collaborative ther-
apeutic alliance
3. Use a cognitive conceptualization to plan
treatment within sessions and across sessions
4. Continually monitor progress
5. Structure sessions to maximize progress
6. Focus on helping patients solve or cope with
current problems and achieve their goals, us-
ing a variety of techniques (20)
7. Identify and help patients modify their key
dysfunctional cognitions
8. Facilitate behavioral change
9. Work directly on treatment compliance
10. Emphasize relapse prevention
Certain basic values and attitudes are important in
becoming proficient in cognitive therapy and achiev-
ing competency. Cognitive therapists place a high pri-
ority on helping patients reduce symptoms quickly.
They demonstrate the characteristics of any good
therapist: genuine empathy, caring, regard, and ac-
curate understanding. They value a collaborative
working relationship and fine-tune their style and the
process of therapy to suit individual patients (7).
Many of the references that follow this article are ben-
eficial resources for training directors to help resi-
dents become skilled practitioners.
CURRICULAR ELEMENTS
Effective, focused CBT training results in improved
therapist competence and patient outcomes (21,22,23).
For adequate training to occur, a substantial period of
theoretical (didactic) training and supervised clinical
experience is needed. Because studies vary with re-
spect to the sophistication and prior therapy experi-
ence of trainees, it is difficult to directly generalize to
the education of psychiatric residents. Most studies of
advanced trainees emphasize a minimum of 6 months
(24–30 hours) of didactic lecture, along with at least 2
hours per week of clinical work with patients and 2
Academic Psychiatry, 27:3, Fall 2003
SUDAK ET AL.
hours per week of supervision for a 6- to 12-month
period of time (21,24,25,26). Brief training carries the
danger of inadequately preparing trainees. One study
found that trainees overestimated their knowledge
and competence in CBT when training length was in-
sufficient to produce competence (26).
Competence in CBT involves both adherence to
the model as well as skillful application of treatment
methods in caring for patients. Therefore, residents
first should be taught general psychotherapy skills
(27), then the model of cognitive psychopathology and
conceptualization, and finally the tools and techniques
of treatment, including guided discovery, Socratic
questioning, collaborative empiricism, and behavioral
techniques (28). Case conceptualization is a key part
of the educational process (29,30). Focused and suffi-
cient supervised, clinical practice must accompany
teaching, since knowledge without application rarely
changes skill development (31). Application of the
treatment techniques without conceptualization fur-
thers the misconception of CBT as a “bag of tricks”
(29) or a rigid, manual-driven approach suitable only
for a very narrow group of patients.
Training can also be enhanced by self-practice
and self-reflection (32). When residents use CBT tools
and techniques on themselves, they develop a more
complete understanding of implementation and mo-
tivational strategies. When residents are successful in
reducing anxiety or solving problems, they become
more enthusiastic in recommending CBT techniques
to their patients. Practicing with their own thought
records, activity schedules, and data logs help resi-
dents increase their self-knowledge, and thereby, in-
crease internal reflection about therapeutic concep-
tualization, progress, and outcome.
Role playing and observation of master clinicians
performing therapy via audiotape, videotape, or live
patient interviews are also crucial methods of edu-
cating residents. The most effective teaching process
involves using the techniques of the treatment—that
is, an active, collaborative instructor who uses an
agenda, guided discovery, feedback, and homework
to help residents attain proficiency.
The need for systematic and thorough training
for residents in CBT is underscored by the ACGME
competency requirements. One danger of proposing
this requirement, however, is that residents who are
graduated as competent practitioners may actually be
inadequately prepared, unless they are involved in
155
COGNITIVE BEHAVIORAL THERAPY
robust CBT training programs with close supervision
and assessment. Training programs must adequately
supervise written examples of case conceptualization
and treatment planning and carefully evaluate audio
or video tapes of residents’ sessions with patients.
Such evaluation should include, at a minimum, an
assessment of how well the resident maintains a col-
laborative therapeutic relationship, sets a satisfactory
agenda, develops an efficient and effective cognitive
or behavioral intervention within the session, sum-
marizes, obtains and addresses feedback, and assigns
relevant homework (33).
Assessment Tools
There are several different assessment tools avail-
able for evaluating the performance of residents who
are learning cognitive therapy. We describe four of
these measures here: The Cognitive Therapy Scale
(34,35,36), The Academy of Cognitive Therapy Case
Formulation Rating (37), The Cognitive Therapy
Awareness Scale (38), and the Cognitive Therapy Su-
pervision Checklist (39). Each of these tools has
unique features that can assist educators in assessing
the knowledge and skills of psychiatry residents.
The Cognitive Therapy Scale (CTS) (34,35,36) has
been the standard measure of competence in cogni-
tive therapy for more than 20 years. This scale is used
widely in training programs in cognitive therapy as
a structured method of rating therapy sessions and
providing feedback. It is also used extensively in cog-
nitive therapy outcome studies to measure the com-
petence of research therapists. The Academy of Cog-
nitive Therapy, a multidisciplinary certifying
organization, uses the CTS as a primary measure for
certifying clinicians in cognitive therapy.
The Cognitive Therapy Scale has 11 items di-
vided into two domains: General Therapeutic Skills
(e.g., agenda setting, interpersonal effectiveness, col-
laboration); Conceptualization, Strategy, and Tech-
nique (e.g., guided discovery, focusing on key cog-
nitions and behaviors, strategy for change, and
homework). Each item is rated on a 0–6 scale. The
highest possible score on the CTS is 66. A score of 40
is the usual cutoff for defining competency for cog-
nitive therapists who participate in outcome research
studies, and the passing score for certification by the
Academy of Cognitive Therapy is 40. In our training
programs we have found that the CTS is most useful
156
as a tool for giving residents specific instruction in
the key elements of effective cognitive therapy ses-
sions. The actual numerical score is of less value than
detailed feedback on performance in each of the rat-
ing categories. However, we generally recommend
that residents score at least 40 on one or more CTS
ratings before completing their training in CBT.
The Cognitive Formulation Rating Scale (CFRS)
was developed by the Academy of Cognitive Ther-
apy as a method of assessing a clinician’s ability to
conceptualize a case based on the cognitive behav-
ioral model and to plan treatment. Ratings on the
CFRS are conducted in three main areas: Case History
(2 items), Case Formulation (5 items), and Treatment
Plan and Course of Therapy (5 items). Each item is
rated on a 3-point scale (0 ⳱ not present, 1 ⳱ present
but inadequate, 2 ⳱ present and adequate).
In the Formulation section of the CFRS, clinicians
are asked to describe precipitants of the disorder, cur-
rent cognitions and behaviors that are contributing to
the problem, developmental considerations in symp-
tom production, the patient’s strengths and assets,
and a summary of the case conceptualization. The
treatment plan and course of therapy include ratings
on items such as treatment goals, interventions
planned and practiced, and how the clinician ap-
proached obstacles to the treatment plan. The Acad-
emy of Cognitive Therapy criterion for a passing
score on the CFRS is 20 out of 24 total possible points.
We have been using this case formulation write-up
format in our cognitive therapy training programs
and have found that residents usually appreciate the
structured methods, examples, and feedback that this
system provides. We have found that most residents
are able to attain a score of 20 on the CFRS after com-
pleting a basic didactic course of 16–20 hours and
treating 2–5 patients with CBT.
The Cognitive Therapy Awareness Scale (CTAS)
(38) was originally designed as a method of measur-
ing the acquisition of basic knowledge of cognitive
therapy concepts and methods in patients who are
being treated with this approach. However, it is also
being used in residency training programs as a stan-
dardized pre- and postmeasure for changes in knowl-
edge associated with participation in cognitive ther-
apy courses. The CTAS has 40 true/ false questions
on topics such as definitions of automatic thoughts
and schemas; description of thought records, activity
schedules, and other commonly used treatment
Academic Psychiatry, 27:3, Fall 2003

methods; and identification of maladaptive thinking
in case illustrations.
The maximum score on the CTAS is 40. A score of
about 20 would be expected if one knew nothing about
cognitive therapy. A study of 96 patients who used a
computer program to help them learn cognitive ther-
apy skills found an increase from a mean score of 24.2
before using the software to 32.5 after completing the
computer training (38). The CTAS has not been stud-
ied systematically in psychiatry training programs.
However, our experience to date indicates that resi-
dents typically have mean CTAS scores in the mid-20s
to lower 30s before starting formal training in cogni-
tive therapy. Most residents have a substantially
higher CTAS score after completing a comprehensive
course in cognitive behavior theory and methods.
The fourth assessment tool, the Cognitive Behav-
ior Therapy Supervision Checklist (39), can be used
to track resident progress in achieving specific com-
petencies. As with the other measures, the CBT Su-
pervision Checklist serves its most important func-
tion in coaching residents on the critical elements of
effective therapy. It also can serve as a record of the
resident’s fulfillment of training goals.
The items on the CBT Supervision Checklist are
based on those recommended by the AADPRT task
force on psychotherapy competencies. They include
evaluations of general therapy skills in addition to
specific cognitive therapy interventions, such as set-
ting agendas and structuring therapy, modifying au-
tomatic thoughts and beliefs, and assigning useful
homework.
Sources for the assessment tools described here
are (1) Cognitive Therapy Scale and Manual: Acad-
emy of Cognitive Therapy Web site (http://acade-
myofct.org); (2) Cognitive Therapy Formulation Rat-
ing Scale (plus instructions for developing case
conceptualization and an example of a formulation),
Academy of Cognitive Therapy Web site; (3) Cogni-
tive Therapy Awareness Scale, Wright et al., 2002 (38);
(4) Cognitive Therapy Supervision Checklist—Donna
Sudak, M.D. (donna.sudak@drexel.edu).
OBSTACLES TO EFFECTIVE TRAINING
The most significant obstacle in teaching residents
CBT is a lack of faculty expertise in some academic
departments of psychiatry. Psychiatrists are not well
represented in specialty organizations that certify CBT
Academic Psychiatry, 27:3, Fall 2003
SUDAK ET AL.
competence (ACT, ABPP) and have not traditionally
sought further training in this method of psychother-
apy, as compared to psychodynamic psychotherapy.
There are also fewer specialty training institutes of
CBT, as compared to psychoanalysis, which can be
used as sources for paid or volunteer faculty.
Programs can creatively increase faculty exper-
tise in several ways:
1. Providing faculty members with comprehen-
sive training in CBT at a specialized institute
(e.g., an extramural fellowship at a recognized
institute for cognitive therapy training) for one
or two faculty members who can teach both
faculty and residents.
2. Acquiring psychoeducational materials such
as videotapes of master therapists, CBT books,
and computer programs that teach basic CBT
methods (40,41).
3. Arranging supervision of faculty trainees by
telephone or teleconference with experts in
CBT.
4. Coordinating a series of workshops for faculty
and residents led by experienced cognitive
therapists.
5. Recruiting trained community practitioners
who could serve as paid or volunteer faculty.
6. Affiliating with university departments of
psychology, psychology internships, nursing,
social work, or other allied health fields with
faculty expertise in CBT. These departments
may require some teaching by psychiatrists
(i.e., in psychopharmacology) so that a “trade”
for faculty time can be made.
Other obstacles to effective training are the faulty be-
liefs that many residents and faculty have about CBT
or psychotherapy in general. These can include be-
liefs that cognitive therapy is mechanical and suitable
only for a narrow range of patients, lacks value for
the therapeutic relationship, and discounts any ex-
ploration of development in working with patients.
Such beliefs can be modified by educating an entire
department as well as by adopting an empirical ap-
proach to the implementation of the treatment and
training. Scheduled departmental conferences and
grand rounds focusing on CBT related topics can in-
crease faculty comfort and familiarity with this ap-
proach. A commonly related problem is the need to
157
COGNITIVE BEHAVIORAL THERAPY
directly address the concern that residents and fac-
ulty have about taping sessions. Again, adopting an
empirical approach is helpful, as well as teaching res-
idents to evaluate their automatic thoughts, generally
about performance or close supervision. Noticeably,
the connotation of competency implies the need to
directly observe resident performance to ensure skill-
ful application of treatment.
Departments will also need to face the challenge
of finding time in the didactic schedule for teaching.
The mandate for competency will assist program di-
rectors in this regard, but it is preferable to do so
without infringing on other didactic requirements.
Additionally, residents commonly believe that there
are few or no suitable CBT patients in the available
resident outpatient caseload. A number of ap-
proaches can be helpful in this situation. First, the
resident didactic training can emphasize working
with the patients the resident is most likely to en-
counter (e.g., CBT for depression, anxiety disorders,
personality disorders, or bipolar disorder). Second,
CBT does not need to be taught as an exclusively out-
patient discipline. Many models exist for implement-
ing training in inpatient settings (15,42), with patients
with severe mental disorders (8,43,44,45), and medi-
cally ill patients (46,47,48). Third, in medication clin-
ics, residents can learn how to use CBT techniques to
enhance medication compliance with any patient
(8,49). This venue should not take the place of con-
ducting a full course of psychotherapy with other pa-
tients, but it has the added advantage of meeting the
competency requirement for combined medication
and psychotherapy cases. The widespread efficacy of
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