While the NACBTp Network is not a certifying organization, we recognize the need to identify clear expectations and performance metrics for clinicians who wish to provide competent and adherent CBT for psychosis. CBT certification indicates to service users and families, employers, and other clinicians that the individual is a skilled cognitive therapist. In addition, the NACBTp recognizes that the identification of core competencies enhances transparency in both the provision of high-quality clinical services as well as in CBTp training. The NACBTp offers Competence Standards for formulation-based CBTp and CBTp training, supervision, or consultancy. We also provide guidance on CBTp-informed care competence standards.
The North American Cognitive Behavioral Therapy for Psychosis Network is an organization of health care professionals, academics and researchers who came together in large part as a reaction to the absence of clear training standards for CBTp in North America, and in response to a recognition of the relative lack of adequate training, consultation and supervision opportunities for clinicians who are working with often complex and vulnerable clients.
The mission statement of the NACBTPN states its goals as follows:
The mission statement of the NACBTPN states its goals as follows:
a. To further the availability of quality, effective, evidence-based training in CBT for psychosis throughout North America, which in turn will increase access to CBTp for consumers
b. To consider issues of competency, how this is defined and measured in training, and how we can contribute to standards of competency in North American CBTp going forward
c. Toward these issues, to discuss training and implementation of CBTp skills or CBTp informed care along the lines of a ‘tiered approach’ to ensure that all practitioners, regardless of their level of training, receive recognition
d. To share training materials, relevant literature, and discuss challenging clinical cases and foster a community of CBTp practitioners
e. To create a clinician directory per state/province/region of people who are trained and capable of offering CBTp (individual or group)
In keeping with this mission statement, an additional formal goal of the NACBTPN has been to:
Develop and promote evidence-based standards (incl. definitions of terms) and certification criteria for
i. CBTp Competency
ii. CBTp Informed Care
iii. CBTp Competency in Training , Consultation & Supervision
These proposed standards have been based, in large part, on existing standards of competence and accreditation coming out of the extensive work in the United Kingdom, with particular attention paid to the following references, which serve as the basis for all CBTp accredited training programs in the UK.
Roth, A.D. & Pilling, S. (2013). A competence framework for psychological interventions with people with psychosis and bipolar disorder. https://www.ucl.ac.uk/pals/research/clinical-educational-and-health-psychology/research-groups/core/competence-frameworks
Morrison, A.P., & Barratt, S. (2010). What are the components of CBT for Psychosis? A Delphi study. Schizophrenia Bulletin, 36 (1), 136-142 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2800146/
In addition, attention has paid to existing standards of accreditation for general CBT coming out of North American CBT bodies such as the Academy of Cognitive Therapy (ACT) and the Canadian Association of Cognitive and Behavioral Therapies (CACBT).
NACBTPN Position on Training and Competence
The position of the NACBTPN is that competence in provision of CBTp is attained through rigorous training, consultation and/or supervision, inclusive of the following elements:
Training consistent with needs of learners, as assessed by an initial formal assessment of these needs (although this may not be possible in some settings where training is offered to diverse groups of learners from multiple settings)
Recognition that awareness of learning needs is crucial in order to determine the level of training in CBTp that would be required to reach either
competence in CBTp, or
competence in CBTp-informed care
and recognition that each of these levels of competence require significantly different levels of training and skill development
Longitudinal consultation and/or supervision of CBTp clients
Recognition that in order to achieve a level of competence, all learners ought to be evaluated and assessed for adherence to CBTp. Evaluation ought to include consideration of CBTp intervention skills as well abilities in case formulation and treatment planning
Criteria for Competence in CBTp
Competence in General CBT
In order to provide CBTp competent training, consultation and supervision, providers must both have obtained full-competency in CBTp themselves, as well as specialized training and competency in each of the areas outlined below.
1. Individuals who are competent in CBTp must also be able to demonstrate competence in generic psychotherapy skills (e.g., establishing a therapeutic alliance, identifying appropriate goals and pacing, managing ruptures) as well as competence in general CBT theory and skills (e.g., conceptualizing cases from a cognitive framework, setting agendas, assigning homework, ability to select and implement appropriate cognitive restructuring and behavioral skills) related to common disorders of mood and anxiety.
Some individuals may come to CBTp training with this competence in general CBT already established. This would include both those individuals who have been certified by the Academy of Cognitive Therapy (ACT) or the Canadian Association of Cognitive and Behavioural Therapies (CACBT), or an equivalent accrediting body, or those who have completed a similar level of training and supervision or consultation on cases (i.e., a minimum of 40 hours of didactic training and/or graduate coursework, 10 supervised cases, evaluation of adherence, and presentation of case conceptualizations and treatment summaries). For many other individuals, this training will need to be incorporated into training efforts for CBTp.
CBTp specific training requirements, in addition to competence in general CBT as described above
2. Must have received didactic training in CBTp, by a CBTp competent trainer (see section below for a more complete list of criteria defining ‘CBTp competent’ training, supervision, and consultation)
Training must be consistent with criteria and competencies outlined in both Roth & Pilling (2013) and Morrison & Barratt (2010)
Didactic training must include information and reference materials for common comorbidities that may not be addressed in general CBT training (e.g., trauma, substance use, OCD) as well as working with cognitive deficits and addressing stigma and cultural competence as related to working with psychosis
This would involve a minimum of 40 hours of didactic training over the course of the initial didactic training period with additional follow-up consultation and/or supervision by a competent CBTp trainer/supervisor/consultant. Typically, CBTp competent trainers will suggest an initial didactic training of 3-5 days in order to assure coverage of the bulk of the required competencies, with additional didactic training during the follow-up consultation as well as assigned reading of a minimum of 5 recommended CBTp books.
3. Must have received consultation and/or supervision in provision of CBTp to 8 individual clients for a duration of a minimum of 16 sessions (up to 2 groups can also be counted towards this total if they are cofacilitated by a CBTp competent practitioner)
4. Adherence to model must be evaluated through submission of session recordings, taken from various points in treatment (i.e., from initial, middle and final stages of treatment) and representing a variety of clinical presentations (i.e., individuals presenting with different distressing positive and/or negative symptoms) and a minimum of 3 of these must reach an acceptable level of adherence (with ongoing submission of sessions until an acceptable level of adherence is achieved) using a validated competency measure (e.g., CTSR or CTRS) with established cutoff scores for competency.
5. Ability to formulate cases and plan treatment must be formally evaluated through submission of case formulations and treatment plans
Typically, the above would be completed over a minimum of a 6-month to 1-year period for those individuals who are coming to CBTp training with established competence in general CBT
Proposed criteria for certification in CBTp that ought to be considered by accrediting bodies would include the competence criteria outlined in 1-5 above, along with the following:
6. Must be licensed for autonomous practice and eligible to provide psychotherapy in their State/Province
7. Must carry liability insurance
8. Evidence of 1-5 above, including submission of recorded sessions, case formulations and treatment plans
9. Two letters of reference from supervisors or from other practitioners who are familiar with the clinician’s work and who meet criteria for CBTp competence themselves
Criteria for Competence in Delivery of CBTp Training, Consultation & Supervision:
Must be competent in CBTp, consistent with the standards outlined above
Must have extensive experience (typically a minimum of 5 years) in provision of CBTp related to a variety of different clinical presentations, and ideally in a number of different contexts (e.g., inpatient, outpatient and day-treatment settings) and formats (e.g., individual and group-based CBTp)
Competence in CBTp consultation and supervision requires formal training in both the use of standardized fidelity rating measures and the provision of fidelity feedback. This would typically include demonstrated competence on the scoring of standardized audio samples provided by a credentialing body, or the achievement of inter-rater reliability with a CBTp competent trainer on a minimum of 3 samples.
Competence in CBTp consultation and supervision requires formal training in provision of consultation and/or supervision, along with an ability to demonstrate each of the core competencies outlined in Table 3 (in addition to 1-3 above). Formal training in supervision/consultation would typically include at least 30 hours of didactic training and self-study related to consultation and supervision, as well as supervision of their supervision (through direct observation or review of recordings of their supervision, as well as ongoing discussion and feedback of same by a CBTp competent trainer) for a minimum of 20 hours or 5 cases.
Competence in CBTp training requires all of the competencies outlined in Table 4 (in addition to 1-4 above). That is, competency in training of CBTp requires that trainers have achieved full competence in CBTp themselves, and that they have extensive experience in both provision of CBTp and in consultation and/or supervision of trainees at a variety of different skill-levels. Given the relative lack of formal training opportunities in provision of training, competence in CBTp training is typically both facilitated and evaluated by starting with co-facilitation of trainings with a fully-competent CBTp trainer
Discussion of Proposed Criteria for Competence in CBTp-Informed Care
The NACBTPN recognizes that there is great variability that exists in terms of what might be recognized as “CBTp-informed care”, and thus the criteria for competence are much more difficult to define. There is likely a wide range of skill and competence that will fall under this umbrella, as CBTp-informed care might include clinicians in varied roles who are not seeking to provide full CBTp in individual or group formats, but may be providing CBTp-informed case management, co-facilitating manualized CBTp-skills based groups, or may be utilizing some CBTp skills in the course of provision of treatment to individuals with psychosis. Clinicians who are competent in CBTp-informed care will require both basic psychotherapy/counselling skills and training in CBTp, but would not be expected to have all of the required knowledge and competence to formulate cases and develop independent and comprehensive treatment plans.
However, training to competence in CBTp-informed care does require more than brief didactic training. That is, each of the elements of CBTp competency consistent training must be present (e.g., assessment of learning needs, didactic training, ongoing supervision or consultation, and evaluation of competence).
1 These criteria for didactic training, consultation and supervision are based on a review of the literature, consideration of the depth and breadth of CBTp components/criteria defined in Roth & Pilling (2013) & Morrison & Barratt (2010), consultation with international CBTp experts, as well as cross referencing of certification criteria for other therapeutic approaches (e.g., Emotion Focused Therapy, Motivational Interviewing, Mindfulness Based Stress Reduction etc,..). Consistent with Brabban et al. (2016), these criteria were developed due to the complexity of psychosis and CBTp and the professional imperative of minimizing harm by ensuring adequate training, consultation and supervision in the provision of competent CBTp.
2 The CBTp specific training requirements (points 2 – 5 above) must be provided by and/or evaluated by a CBTp competent trainer/supervisor or CBTp credentialing body
3 The NACBTPN is not a credentialing body, but is working to recommend certification processes and grandparenting procedures
Citation: North American CBT for Psychosis Network. (2020). RESOURCES: CBTp Competency Standards. https://www.nacbtp.org/competencies