Scaling Therapy Supervision: Assessing Psychotherapy Fidelity Using Large Language Models

Psychotherapy fidelity assessment measures how faithfully a therapist adheres to a treatment protocol, a critical determinant of positive patient outcomes. However, fidelity assessment is bottlenecked by manual expert review, rendering the process labor-intensive and unscalable. To scale therapy supervision and support clinician self-learning, we present an integrated application of large language models (LLMs) that automates psychotherapy fidelity workflows and generates actionable supervisory feedback from authentic, long-form clinical transcripts. We evaluate three open-weight models across multiple task decomposition configurations and reasoning strategies, demonstrating that evidence-first reasoning improves fidelity estimation. Furthermore, we establish the framework's external construct validity on an independent randomized controlled trial (RCT), where it reliably distinguishes Cognitive Behavioral Therapy (CBT) from non-CBT sessions across core therapeutic skills. Through a user study that evaluates the generated feedback, mental health experts indicate that the pipeline synthesizes actionable clinical feedback. Ultimately, our work offers a practical, scalable solution toward bridging the community mental health supervision gap.