CTS-R Explained: A Guide for CBT Trainees

The CTS-R (Cognitive Therapy Scale – Revised) is a 12-item, observer-rated scale for judging a therapist's competence in one recorded CBT session. Each item is rated from 0 to 6, giving a maximum of 72, and the manual's authors set a minimum competence standard of 36 (James et al., 2001).

If you are training in CBT in the UK, you are likely to have sessions rated on it. Many courses use it to mark recordings, it can feature in accreditation portfolios, and it gives supervisors a shared language for feedback. Yet trainees often meet it first as a score on a form. This guide explains what each item assesses, how rating works and how to use the scale for self-assessment. It describes the items in our own words and does not reproduce the manual's rating descriptors; for those, use the published manual and your course materials.

What is the CTS-R?

The Cognitive Therapy Scale – Revised (CTS-R) is an observer-rated measure of competence in cognitive behavioural therapy. It was developed by clinicians and researchers at the Newcastle Cognitive and Behavioural Therapies Centre and Newcastle University (Blackburn et al., 2001; James et al., 2001) as a revision of the original Cognitive Therapy Scale (Young & Beck, 1980). A rater, usually a supervisor, tutor or assessor, listens to or watches a recorded session and rates the therapist's performance across a set of competencies.

A few features are worth knowing from the start:

It rates the therapist, not the client. The CTS-R looks at what the therapist did in the session, not whether the client improved.
It rates one session. A score describes a single recording. It is a snapshot, which is why courses and portfolios typically ask for several rated sessions over time.
It covers both general and CBT-specific skills. Some items concern the structure and relationship of any good therapy session; others concern the specific methods of cognitive therapy.
It is a developmental tool as much as an assessment tool. Used well, it tells you which skills are carrying your sessions and which need work.

The 12 items

The CTS-R has 12 items. The manual divides them into general therapy items (1–5) and cognitive therapy-specific items (6–12), with agenda setting counting as both (James et al., 2001). The descriptions below are our summaries of each item's purpose, not the manual's wording.

General therapy items (1–5)

1. Agenda setting and adherence. Whether the therapist and client agree on what the session will cover, and whether the session then follows that plan, or departs from it for good reason and by agreement.
2. Feedback. Whether feedback flows in both directions: the therapist checks the client's understanding and reactions, and also offers the client clear summaries.
3. Collaboration. Whether the work is done with the client as an active partner, sharing decisions and problem-solving together rather than the therapist leading alone.
4. Pacing and efficient use of time. Whether the session moves at a speed that suits the client and the material, without rushing important work or drifting.
5. Interpersonal effectiveness. Whether the therapist conveys warmth, genuineness, empathy and understanding in a way that helps the client engage with the work.

Cognitive therapy items (6–12)

6. Eliciting appropriate emotional expression. Whether the therapist helps the client access and express emotion at a level that is useful for the work, neither avoiding feeling nor letting it overwhelm the session.
7. Eliciting key cognitions. Whether the therapist helps the client identify the thoughts, images, assumptions and beliefs that matter most for the problem.
8. Eliciting behaviours. Whether the therapist identifies the behaviours that are relevant to the problem, such as avoidance, safety behaviours or withdrawal, and how they maintain it.
9. Guided discovery. Whether the therapist uses questioning and exploration to help the client arrive at new understanding themselves, rather than being told or persuaded.
10. Conceptual integration. Whether the therapist's work in the session is guided by a formulation, and whether the links between the client's difficulties and the model are made clear.
11. Application of change methods. Whether the therapist uses cognitive and behavioural change techniques appropriately, skilfully and in line with the formulation.
12. Homework setting. Whether a between-session task is agreed that follows from the session, has a clear rationale, and is planned in enough detail to be carried out.

Notice how much the items depend on each other. Good conceptual integration makes it easier to choose the right change methods and to set homework that follows from the session. Weak agenda setting often shows up later as poor pacing. When a score is low on one item, it is worth asking which other item might be driving it.

How the rating works

Each item is rated on a seven-point scale from 0 to 6, and half points can be used. The levels are mapped onto an adapted Dreyfus model of competence, running from incompetent through novice, advanced beginner, competent and proficient to expert, with 3 broadly marking competent practice that still has some problems (James et al., 2001). Raters consider both whether a skill was present and how well it was used, including how the therapist handled difficulties in the session.

Scores across the 12 items add up to a total out of 72. The manual's authors set a minimum competence standard of 36, an average of 3 per item, at their Newcastle centre (James et al., 2001), and that figure is widely used as a benchmark. Your course or accrediting body sets the standard that applies to you, and some settings also look at individual items rather than only the total.

A few practical points about rating:

Context matters. A session with a highly distressed client, or an early assessment session, may give fewer chances to show some skills. Raters take this into account, but it is worth choosing recordings that show the range of your work.
Not every item applies equally to every session. Discuss with your supervisor how to handle items that were not a focus of that session.
Raters differ. In the original psychometric study, the scale showed high internal consistency and adequate overall inter-rater reliability, but agreement on individual items varied widely between pairs of raters (Blackburn et al., 2001). Calibration exercises, where several raters score the same recording, help keep standards consistent.

For how the CTS-R fits into the accreditation process, see BABCP accreditation: the complete UK guide.

Interactive worksheet

CTS-R Self-Assessment

Rate your own recorded sessions against the CTS-R competencies before a formal assessment — see what is carrying your sessions and what needs work.

Try this worksheetFree · opens in your browser · no sign-up

Using the CTS-R for self-assessment

Self-rating is one of the most useful things you can do with the scale, long before a formal assessment. It is uncomfortable, but listening back to your own sessions against the items shows you patterns you cannot see from inside the room.

A practical routine:

Record regularly. With the client's consent and in line with your service's policies, record sessions routinely so that being recorded feels normal.
Rate a full session, not highlights. Listen from start to finish. Many of the items, such as agenda setting, pacing and homework, can only be judged across the whole session.
Note timestamps. For each item, note one or two moments that support your rating. This turns a number into something you can discuss.
Pick one or two items to work on. Trying to improve all 12 at once rarely works. Choose the items where a change would make the biggest difference to the session.
Compare with your supervisor. Ask your supervisor to rate the same recording, then compare. Differences are often more instructive than the scores themselves.
Track over time. Keep your ratings so you can see how each item develops across a placement or training year.

A short example (fictional composite)

Please note: "Alex" is a fictional trainee, a composite written for teaching. No real session material is used.

Alex self-rates a session with a client with social anxiety and notices that most items feel reasonable, but homework setting feels weak. Listening back, Alex finds that homework was raised in the last two minutes, with no rationale and no discussion of obstacles.

Looking further, Alex realises the real issue is earlier: the agenda did not include time for homework, and the session over-ran on reviewing the week. So the change Alex takes to the next session is not "do homework better" but "put homework on the agenda and keep an eye on time after the review". That is the kind of link between items that self-rating makes visible.

Common difficulties trainees notice

These themes come up often when trainees start rating their own work:

Agenda set, then abandoned. An agenda is agreed but the session drifts without discussing the change.
Feedback only at the end. The therapist asks "how was today?" but does not check understanding during the session.
Telling instead of guided discovery. The therapist offers the alternative thought rather than helping the client find it.
Techniques without a formulation. A change method is used because it is familiar, not because the formulation points to it. This affects both conceptual integration and application of change methods.
Emotion kept at arm's length. The session stays at an intellectual level, and the client's feelings are named but not explored.
Homework added on. Homework does not follow from the session and has no clear plan.

Many of these link back to formulation. If you are unsure how your session work connects to a model, the free CBT formulation model explainers and the cross-sectional formulation template are good places to start.

Frequently asked questions

How many items are on the CTS-R?

The CTS-R has 12 items. Items 1–5 cover general therapy skills: agenda setting and adherence, feedback, collaboration, pacing and interpersonal effectiveness. Items 6–12 cover cognitive therapy skills: eliciting emotion, cognitions and behaviours, guided discovery, conceptual integration, change methods and homework setting. Each item is rated from 0 to 6, giving a possible total of 72.

What is a passing score on the CTS-R?

There is no single universal pass mark. The CTS-R manual's authors set a minimum competence standard of 36 out of 72, an average of 3 per item, and many settings use that figure as a benchmark. Your course or accrediting body sets the actual standard, which may include minimum scores on particular items, so check the requirements that apply to you.

Can I use the CTS-R to rate my own sessions?

Yes. Self-rating recorded sessions is a common way to prepare for formal assessment, as long as you have the client's consent to record and follow your service's policies. It works best when you rate full sessions rather than highlights, note a timestamped example for each item, and compare your ratings with your supervisor's rating of the same recording.

Where to start

Record one session this week, listen to it in full, and rate it against the 12 items using your course's copy of the scale. Pick the one item where a change would help most, log your ratings on the CTS-R Self-Assessment worksheet, and bring it to supervision with a timestamped example. Repeated over a placement, that habit does more for your CTS-R scores than any amount of reading.

Working towards CTS-R-rated recordings? Formulate includes a CTS-R self-assessment worksheet alongside supervision and formulation tools, with 50% off any paid plan for verified trainees. See trainee plans →

References

Blackburn, I.-M., James, I. A., Milne, D. L., Baker, C., Standart, S., Garland, A., & Reichelt, F. K. (2001). The revised cognitive therapy scale (CTS-R): Psychometric properties. Behavioural and Cognitive Psychotherapy, 29(4), 431–446.

James, I. A., Blackburn, I.-M., & Reichelt, F. K. (2001). Manual of the Revised Cognitive Therapy Scale (CTS-R). Newcastle Cognitive and Behavioural Therapies Centre.

Young, J. E., & Beck, A. T. (1980). Cognitive Therapy Scale: Rating manual [Unpublished manuscript]. University of Pennsylvania.

This article is for trainee and qualified clinicians and is educational, not clinical advice. It summarises the CTS-R's items in our own words and does not reproduce the scale or its manual. Thresholds and assessment requirements are set by your course, assessor or accrediting body; always check the current requirements that apply to you. The example is a fictional composite.