(CTS‐R) (Blackburn et al. 2001). This is a revised version of the original Cognitive Therapy Scale developed by Young and Beck (1988). The CTS‐R consists of 12 items which assess important generic CBT skills. These include four general skills (feedback; collaboration; pacing and efficient use of time; and interpersonal effectiveness) and seven specific CBT skills (eliciting appropriate emotional expression; eliciting key cognitions; eliciting behaviours; guided discovery; conceptual integration; application of change methods; and homework setting). The remaining item, agenda setting, overlaps both sets of items and is included in the general and specific sub‐scales.
The suitability of the CTS‐R to assess competencies when using CBT with children and adolescents has been questioned (Fuggle et al. 2012). In particular, the authors argue that the CTS‐R is not appropriate because:
Important systemic influences on the onset and maintenance of the young person’s problems need to be acknowledged and the role of the carers/family in CBT considered.
The young person’s cognitive, emotional, linguistic, and reasoning ability are developing, and CBT needs to be appropriately adapted to be consistent with their abilities.
Creative non‐verbal methods may be required to convey the concepts of CBT to young people in clear and understandable ways.
The process of undertaking CBT with young people and their carers needs greater specification.
Specific CBT competence scales for use with children and young people have been developed and evaluated. Of those available, the majority assess competence in delivering a specific manualised programme or treatments for specific disorders. For example, Mcleod et al. (2019) developed a scale to assess competence delivering the Coping Cat anxiety programme, Bjaastad et al. (2016) the FRIENDS anxiety programme, and Gutermann et al. (2015) for assessing competence in treating PTSD. Although there are some differences in the competencies that have been identified, there are several shared dimensions. For instance, in a Delphi study, Sburlati et al. (2011) identified various generic therapeutic competencies (e.g. practising professionally, knowledge of children and adolescents, building a positive relationship, conducting a thorough assessment), CBT‐specific competencies (e.g. understanding CBT theory, developing a CBT formulation, working collaboratively), and specific CBT techniques (e.g. managing negative thoughts, changing maladaptive behaviours, managing maladaptive mood). McLeod et al. 2018 identified four categories of competence for delivering anxiety interventions. These are interventions that are common to CBT programmes (e.g. maintaining focus on CBT model, homework review, etc.), interventions specific to anxiety programmes (e.g. relaxation, fear ladder, exposure), how the intervention is delivered (coaching, modelling, rehearsal), and overall ratings of skilfulness and responsiveness. Whilst there are some specific differences, there tends to be a consensus that undertaking CBT with children and young people requires competencies both in the method of delivery (e.g. the therapeutic process) and in the application of specific CBT techniques.
Cognitive Behaviour Therapy Scale for Children and Young People
The absence of a psychometrically robust scale developed specifically to assess general CBT competence with children and young people led to the development of the Cognitive Behaviour Therapy Scale for Children and Young People (CBTS‐CYP) (Stallard, Myles, et al. 2014). The aim was to develop a scale to assess the overall quality of CBT, not to assess in detail the way that specific techniques like exposure are conducted.
In terms of development, it was firstly decided to build upon the CTS‐R. The CTS‐R is widely used and considered to provide a comprehensive overview of the generic skills required to competently practise CBT with adults (Fairburn & Cooper 2011; Kazantzis 2003; Keen & Freeston 2008). Secondly, the CTS‐R assesses the specific use of CBT methods as well as general skills that facilitate their effective delivery. It was therefore decided that the CBTS‐CYP would contain items that assessed competence both in the application of specific methods and in the process of using CBT with children and young people. Thirdly, upon reviewing the CTS‐R, it was decided that all items should be included in the CBTS‐CYP, modified as appropriate to reflect the use of CBT with children and young people. Similarly, the framework for defining competence proposed by Dreyfus (1986) and adapted into a seven‐point Likert scale on the CTS‐R was adopted for use in the CBTS‐CYP. Fourthly, the CTS‐R is widely used by CBT training courses to assess competence. In order to maintain consistency with the CTS‐R, it was decided to adopt the same thresholds for assessing competency, that is, score 2 or more on each item and a total score of 50% or more. Finally, it was decided that the scale would be developed to assess both verbal and non‐verbal behaviours and so could be used like the CTS‐R to assess both audio and video recordings of clinical sessions. It was anticipated that specific items would not necessarily be mutually exclusive. For example, a formulation requires the development of a shared conceptualisation in which important cognitions, emotions, and behaviours are bound together within the CBT model. The elicitation and identification of key cognitions and processes would therefore be expected to be associated with the formulation. Similarly, CBT typically involves developing an understanding of the links between cognitions, emotions, and behaviours and as such there will inevitably be overlap between these different aspects of the cognitive behavioural model.
In addition to competencies in the application of core methods, the use of CBT with young people also requires competencies in the way that CBT is provided. CBT is predicated on a process of collaborative empiricism, a process which requires greater attention when working with children, adolescents, and young adults. These competences relating to the therapeutic process have been defined by the acronym PRECISE (Stallard 2005).
P: The therapeutic process involves the young person and their family working in a partnership with the clinician. The partnership is based upon collaborative empiricism and highlights the active roles of the young person and their parents/carers in securing change.
R: The intervention is pitched at the right developmental level to ensure that it is consistent with the young person’s cognitive, linguistic, memory, and perspective‐taking abilities.
E: A warm, caring, respectful, and empathic relationship is established.
C: The concepts of CBT are creatively and flexibly conveyed in a way that matches the young person’s interests and understanding.
I: Investigation and self‐discovery are encouraged through the adoption of a curious and reflective approach.
S: Self‐efficacy is promoted as the young person is helped to discover and build upon their strengths, skills, and ideas.
E: Sessions are enjoyable and engaging in order to maintain the young person’s motivation and commitment to change.
The CBTS‐CYP assesses the above seven PRECISE process items and the following eight method items, referred to as the ABCs of CBT.
A: Assessment , and the ability to establish clear goals and to appropriately use diaries, questionnaires, and rating scales for assessment.
B: Use of behavioural techniques such as graded exposure, behavioural activation, and activity scheduling to facilitate therapeutic change.
C: Use of cognitive techniques to identify cognitions, to promote cognitive awareness, to challenge, to reframe, or to develop mindfulness, acceptance, and compassion.
D: Facilitating discovery using techniques such as the Socratic dialogue, behavioural experiments, and prediction testing.
E: Use of emotional techniques to identify and manage strong, unpleasant emotions.
F: Ability to construct a case formulation which highlights the relationships between events, cognitions, emotions, physiological responses, and behaviour.
G: General skills to effectively manage sessions such as agenda setting, session planning, and managing challenging behaviour
H: Appropriate