Cognitive Analytic Therapy

Description, guidelines, structure, treatments, benefits, effectiveness

Three sections follow:

1.      Background Material that provides the context for the topic

2.      Suggestions for Practice

3.      A list of References

Feedback welcome!

Background Material

What is Cognitive Analytic Therapy (CAT)?

Cognitive Analytic Therapy (CAT) is a highly structured and collaborative form of psychotherapy, developed in the 1980s by Dr. Anthony Ryle.  At the heart of CAT is the idea that many of the problems individuals face in adulthood are shaped by relational patterns and coping strategies developed during childhood. These patterns, which may have served a protective function early in life, can become maladaptive and lead to emotional distress, relationship difficulties, and mental health challenges (ACAT, n.d.; Lockett & Boland, 2023; Magna House, n.d.).  Maladaptive behaviour patterns can be grouped in three types:

• Traps happen when dysfunctional behaviours and negative thought patterns feed on each other, almost in a type of “cycle.” When people aren’t able to recognise these spirals, it keeps them stuck in the trap of these behaviours and thoughts.

• Dilemmas happen when people remain in situations or continue to engage in behaviors in order to avoid a potentially worse alternative. Oftentimes, dilemmas are the result of “either/or” and “if/then” thinking.

• Snags happen when the anticipation of future consequences prevents someone from being able to make choices or engage in behaviours that they want. Sometimes a snag can come from within ― other times, it can come from those around us.

With the help and guidance of a cognitive analytic therapist, a person can learn more about their own history, recognise if they’re engaging in these behaviours, and work to change them (Balmain et al., 2021; Lockett & Boland, 2023).

For example, if a person learned in childhood that s/he only received love and care by pleasing others, the person might believe that ‘only if I do what others want will I be liked’.  This puts the person in a trap of pleasing others and can lead to the person feeling used and abused. Only when the person realises s/he has got used to being in this trap can the person start to notice how often it is happening.  Then the person can begin to change what s/he does – for example, by learning other more useful ways of standing up for him/herself (ACAT, n.d.).

Core Guidelines of Cognitive Analytic Therapy

Cognitive Analytic Therapy is grounded in four core guidelines that guide its practice. These principles shape the therapeutic process and ensure that CAT is a collaborative, person-centred approach that encourages self-awareness and positive change (Magna House, n.d.):

1. Understanding Relational Patterns

As outlined above, one of the key principles of CAT is the recognition that early life experiences, particularly those involving relationships with caregivers, shape people’s beliefs about themselves and others. CAT aims to help individuals identify and understand these relational patterns, explore how they were formed and how they continue to impact their current relationships and emotional well-being. Recognising these patterns ultimately enables individuals to develop more effective ways of relating to themselves and others.

2. Collaboration and Joint Exploration

CAT is a highly collaborative process. The therapist and the person work together to explore the person’s difficulties, with the therapist acting as a guide rather than an authority. Together therapist and person regularly review progress, discuss insights gained during therapy, and make decisions about the direction of the therapy.  This empowers the person to take an active role in his or her own recovery.  This approach ensures that the therapy is tailored to the person’s needs and goals, making it a highly personalised form of treatment.

3. Time-Limited and Goal-Oriented

CAT is a time-limited therapy, typically lasting between 16 and 24 sessions. This structured timeframe helps to keep the therapy focused and goal-oriented, encouraging both the therapist and the person to work towards specific, achievable outcomes within a set period. 

4. Reformulation and Mapping

One of the unique aspects of CAT is the use of reformulation, a process in which the therapist and person work together to create a written or diagrammatic summary of the person’s difficulties—they develop a shared understanding of the presenting problems and associated difficulties (Rafti & Prabalkumari, 2023).  Reformulation can enable the development of trust in the therapist, offer reassurance and make the person feel ‘heard’ leading to the development of a strong working alliance (Balmain et al., 2021).

The Structure of Cognitive Analytic Therapy

An introductory session allows people to introduce themselves and get to know the therapist. During this first session, people review their mental health history, establish the goals for their treatment, and learn more about what CAT is and how it can help them (Lockett & Boland, 2023).  People learn that CAT is divided into three main phases: the early phase (reformulation), the middle phase (recognition and revision), and the ending phase, with each of these phases playing a crucial role in the therapeutic process (Lockett & Boland, 2023; Magna House, n.d.).

1. Early Phase: Reformulation (e.g. sessions 1 to 5)

The early phase of CAT focuses on reformulation, where the therapist and person work together to explore the person’s difficulties and develop a shared understanding of the relational patterns that are contributing to their problems. This phase involves gathering information about the person’s history, including their early relationships, significant life events, and current challenges.  The therapist may use a timeline to show significant events in the person’s life.  The therapist will be particularly interested in the kinds of relationship roles the person experiences. Therapists may ask the person to complete some questionnaires, such as the psychotherapy file, to pick up on any particular patterns that may be causing problems (ACAT, n.d.; Balmain et al., 2021; Lockett & Boland, 2023; Magna House, n.d.). 

During this phase, the therapist may ask the person to keep a diary or journal, recording their thoughts, feelings, and behaviours in specific situations. This helps to identify recurring patterns and themes, which are then used to create a reformulation letter and CAT diagram. The reformulation letter is a written summary of the person’s difficulties, while the CAT diagram visually maps out the relational patterns and coping strategies that are contributing to the person’s distress. The reformulation process is highly collaborative, with the therapist and the person discussing the content of the letter or diagram together. This ensures that the person feels understood and that the reformulation accurately reflects their experiences (ACAT, n.d.; Lockett & Boland, 2023; Magna House, n.d.).

ACAT (n.d.) provides more detail about the reformulation letter and CAT diagram.  This information can be found at https://www.acat.org.uk/cat-explained/what-cat-sessions-are-like/diagrams-and-maps-in-cognitive-analytic-therapy  and https://www.acat.org.uk/cat-explained/what-cat-sessions-are-like/letters-in-cat-the-first-letter 

2. Middle or Active Phase: Recognition and Revision (e.g. sessions 6 to 12)

In this phase, the individual begins to recognise how their relational patterns and coping strategies are contributing to their current difficulties. The CAT diagram serves as a key tool during this phase and is used to help the person recognise when s/he is following unhelpful patterns of behaviour.  Once the person has developed an awareness of their patterns, the focus shifts to revision—the process of making changes to these patterns.  The revision phase involves some of the following:

• Learning new skills, for example relaxation, mindfulness, or how to soothe oneself when difficult feelings come up.

• Learning how to be assertive about what is wanted, including developing skills that will help the person make changes.

• Actively trying to develop a better, kinder, more compassionate “observing eye”.

• Noticing what happens in the relationship between the person and the therapist (e.g. transference and countertransference), and how this may be similar to some of the patterns on the CAT map. 

• Certain traumatic events in the person’s past that are keeping him or her stuck in the past may need to be explored in more detail.

• The person may choose to involve their partner, friends and family in the changes they want to make (ACAT, n.d.; Balmain et al., 2021; Rafti & Prabalkumari, 2023). 

The middle phase of CAT is highly active and focused on change. The person is encouraged to experiment with new behaviours and reflect on the impact of these changes in their day-to-day life. Throughout this phase, the therapist provides support and guidance, helping the person to stay focused on their goals and work through any challenges that arise.   (ACAT, n.d.; Lockett & Boland, 2023; Magna House, n.d.).

CAT therapists strive to work within the service user’s zone of proximal development (ZPD), that is, the space between their actual learning developmental level and their level of potential development. Attention to the ZPD should mean the therapy process is appropriately paced and commensurate with the service user’s understanding and readiness to process information. This should confer a sense of safety (Balmain et al., 2021; Rafti & Prabalkumari, 2023).

At times, some direct techniques from other psychotherapy orientations, such as behavioural activation, exposure–response therapy, distress tolerance, and eye movement desensitisation and reprocessing, can be employed to address some symptoms and maladaptive patterns that are more fixed and unyielding (Rafti & Prabalkumari, 2023).

3. Ending Phase (e.g. sessions 13 to 16)

The ending phase of CAT is an important part of the therapeutic process, as it helps the person to consolidate their progress and prepare for life after therapy. This phase often involves a discussion of endings in general, as CAT recognises that many individuals have difficulty with endings due to past relational experiences. This phase provides an opportunity to explore any feelings of loss, anxiety, or uncertainty that may arise as therapy ends and to work through these emotions in a supportive environment (Magna House, n.d.).

This phase can involve:

• Thinking about previous loss and endings of relationships in the person’s life and how s/he managed to deal with them.

• Reviewing what has been achieved and how to keep any changes going.

• Identifying people in the person’s life with whom the person can discuss issues if they arise.

• Acknowledging sadness about things that cannot be changed, or that will take a long time (ACAT, n.d.).

At the end of CAT, the therapist may provide the person with a goodbye letter, summarising the work that has been done and offering encouragement for the future. This letter serves as a reminder of the progress that has been made and the tools that the person can continue to use in their ongoing journey of self-awareness and growth (ACAT, n.d., Magna House, n.d.).

The therapist may offer the person a follow up appointment at about 3 months to check in and see how the person has been getting on without regular sessions. Persons who had a longer CAT therapy, may be offered additional follow up sessions (ACAT, n.d.; Lockett & Boland, 2023).

Conditions Treated by Cognitive Analytic Therapy

CAT is a highly versatile form of therapy that can be used to treat a wide range of mental health conditions. It is particularly effective for individuals who struggle with complex emotional and relational difficulties, as it helps to address the underlying patterns that contribute to these issues. Some conditions CAT can help with include:

• Personality disorders

• Anxiety and depression

• Trauma and complex PTSD

• Eating disorders

• Interpersonal and relationship difficulties (Magna House, n.d.)

The Benefits of Cognitive Analytic Therapy

CAT can help with a wide range of difficulties, for example:

• experiencing depression

• having anxiety or low self-esteem

• feeling repeatedly feel let down, hurt or rejected

• doing things that are harmful or self-defeating as a way to stop feeling overwhelmed by strong feelings (ACAT, n.d.; Wellspace Psychology, n.d.)

By looking more closely at patterns of thinking, feeling and behaving, the person will:

• clarify which ones are helpful or unhelpful

• understand the effect they are having

• make sense of how they developed and why the person needed them

• start to develop new more helpful patterns, and

• develop a better relationship with others (ACAT, n.d.)

CAT offers numerous benefits for individuals struggling with emotional and relational difficulties. Some of the key benefits include (Magna House, n.d.):

1. Increased Self-Awareness              One of the primary goals of CAT is to help individuals develop a deeper understanding of their thoughts, emotions, and behaviours. By exploring the relational patterns that underlie their difficulties, individuals gain greater self-awareness, which is the first step towards making meaningful changes.

2. Practical Tools for Change         The use of CAT diagrams and reformulation letters helps individuals to identify their patterns of behaviour and develop new tools and strategies to respond to difficult situations, making the therapy both insightful and action oriented.

3. Improved Relationships           Many of the difficulties addressed in CAT are rooted in relational patterns. By helping individuals understand how these patterns influence their relationships, CAT provides a pathway to healthier, more fulfilling connections with others.

4. Time-Limited and Focused           The time-limited nature of CAT ensures that therapy is focused and goal-oriented. Individuals can make significant progress within a relatively short period, gaining the tools they need to continue their growth and development after therapy has ended.

5. Collaborative and Empowering           CAT is a collaborative process that empowers individuals to take an active role in their own recovery. The joint exploration of difficulties fosters a sense of ownership and responsibility for change, which is essential for long-term success.

How effective is cognitive analytic therapy?

There is published literature that includes case studies, small-scale studies, and randomised controlled trials (RCTs) from different parts of the world where CAT is being practiced.  The evidence base is currently dominated by practice-based evidence and requires the additional weight of strictly controlled effectiveness trials (Lockett & Boland, 2023; Rafti & Prabalkumari, 2023).

In one meta-analysis (Hallam, 2021), researchers analysed 28 different studies to discover the effectiveness, durability, and acceptability of CAT. According to the results of the analysis, CAT was effective at helping reduce not only overall mental health symptoms but also interpersonal difficulties and depression.  Moreover, the analysis indicated that effects last beyond the treatment period (Lockett & Boland, 2023; Rafti & Prabalkumari, 2023).

Martin et al., (2021) explored the effectiveness of a 12-week group CAT approach for people with depression and anxiety. Although only a little over 50% of the study participants completed the entire 12-week course, results showed that group CAT was effective at reducing symptoms of stress, anxiety, and depression (Lockett & Boland, 2023).

In an earlier study (Baronian et al., 2020), researchers investigated the role of CAT as a part of pain management services for people with chronic pain. According to the results, as little as eight sessions of CAT improved both well-being and self-efficacy, as well as reduced pain-related appointments (Lockett & Boland, 2023).

Suggestions for Practice

Becoming competent in CAT requires two years of training from an accredited organisation; these organisations can be located via an internet search.  For example, in Australia training is offered through

• https://www.orygen.org.au/CAT

• https://cattrainingaustralia.com.au/training/ 

This training is accredited by the Australian and New Zealand Association of Cognitive Analytic Therapy (ANZACAT) and based on standards set by the International Cognitive Analytic Therapy Association (ICATA) for the training of CAT practitioners. 

Without formal training, CAT still provides approaches that can be incorporated into social work practice.

• Both CAT and social work depend on a strong, supportive therapeutic relationship where persons are comfortable being themselves.    

• CAT reminds social workers of the importance of collaboration.  Collaboration between therapist and the individual enables positive outcomes that are tailored to the person’s strengths.

• CAT emphasises working with people in their ZPD (i.e., zone of proximal development—the the space between their actual learning developmental level and their level of potential development).  This helps ensure therapy and suggested solutions are appropriate and practical for the person. 

• Exploring childhood experiences plays an important role in CAT.  For some individuals and problems, it may be appropriate to explore how long the person has experienced, or been practising, a certain behaviour.

• The reformulation letter and map/diagram are key aspects of CAT.  Likewise, the use of a diary / journal is common.  These approaches may be relevant in other practice models, especially for people who are more comfortable with visual learning.

• CAT therapists are able to supplement CAT with other approaches they can see may be relevant, e.g. behavioural activation, exposure–response therapy, distress tolerance, and eye movement desensitisation and reprocessing.  This reminds social workers to have a selection of practice approaches they can draw upon, depending on the presenting problem.

• CAT reminds social workers of the need to properly end therapy with a person, to transition them away from the support of the therapist to other supports agreed upon during therapy.  Offering a follow up appointment may be a strategy a therapist considers for some people.

References

ACAT: Association for Cognitive Analytic Therapy. (n.d.).  CAT explained.  https://www.acat.org.uk/cat-explained 

Balmain, N., Melia, Y., Dent,H., & Smith,K.  (2021).  A systematic review of service user’s experience of cognitive analytic therapy (CAT).  Psychology and Psychotherapy: Theory, Research and Practice, 94, 36–63.  doi:10.1111/papt.12305

Baronian R, Leggett S. J. (2020). Brief cognitive analytic therapy for adults with chronic pain: a preliminary evaluation of treatment outcome. British Journal of Pain,14(1), 57-67. https://doi.org/10.1177/2049463719858119 

Hallam, C., Simmonds-Buckley, M., Kellett, S., Greenhill, B. and Jones, A. (2021), The acceptability, effectiveness, and durability of cognitive analytic therapy: Systematic review and meta-analysis. Psychology and  Psychotherapy: Theory, Research and practice, 94, 8-35. https://doi.org/10.1111/papt.12286 

Lockett, E., & Boland, M.  (2023).  Your Guide to Cognitive Analytic Therapy (CAT) and Its Benefits.  https://www.healthline.com/health/mental-health/cognitive-analytic-therapy 

Magna House.  (n.d.).  Cognitive analytic therapy (CAT) at Magna House Hospital.  https://www.enbridge.co.uk/psychological-therapies/cognitive-analytic-therapy-cat 

Martin, E., Byrne, G., Connon, G. and Power, L. (2021), An exploration of group cognitive analytic therapy for anxiety and depression. Psychology and Psychotherapy: Theory, Research and practice, 94: 79-95 e12299. https://doi.org/10.1111/papt.12299 

Rafi, A. T., & Prabalkumari, S. (2023).   Cognitive analytic therapy: An innovative psychotherapy framework in the Indian context.  Indian Journal of Psychological Medicine, 45(6), 634-639.  https://doi.org/10.1177/02537176221081778

Wellspace Psychology.  (n.d.).  How can help: Cognitive analytic therapy.  https://www.wellspacepsychology.com.au/how-we-help/cognitive-analytical-therapy-(cat)