Cognitive Analytic Therapy(CAT)
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Overview
Cognitive Analytic Therapy (CAT) is a time-limited, relationally focused integrative psychological therapy that draws on cognitive psychology, psychoanalytic object relations theory, and activity theory (Vygotskian developmental psychology). Developed by Anthony Ryle in the 1980s, CAT helps people understand and change longstanding patterns of thinking, feeling, and relating that cause ongoing distress. It places particular emphasis on understanding how early relational experiences shape current patterns, and uses unique collaborative tools — including reformulation letters and diagrams — to make these patterns visible and open to change.
CAT is not simply a blend of CBT and psychoanalysis. It has its own distinct theoretical model — the Procedural Sequence Object Relations Model (PSORM) — its own tools (sequential diagrammatic reformulation, reformulation and goodbye letters, the Psychotherapy File), and its own understanding of how distress is maintained through repeating relational procedures. Developed by Dr Anthony Ryle at Guy’s Hospital, London, in the 1980s as a public health response to the mental health needs of an inner London population, CAT was designed from the outset to be effective, collaborative, and deliverable within the resources of the NHS. It is inherently collaborative: the therapist and client build a shared understanding together, with the client’s voice central to the process. The therapy honours the reality that many difficulties arise from difficult early experiences and relationships — framing early coping strategies as having been necessary for emotional survival rather than pathologising them.
What this therapy focuses on
CAT helps people recognise repeating patterns — called “procedures” — in how they think, feel, act, and relate to others and themselves. These patterns often developed as understandable responses to early life experiences, but may now cause difficulties. The therapy uses collaboratively created written and visual tools to map these patterns, making them easier to recognise in daily life and creating space to develop alternative, more helpful ways of responding.
A central idea in CAT is that of “reciprocal roles”: the paired relational positions we learned early in life (for example, “critical–criticised” or “neglecting–neglected”). These roles shape how we expect to be treated and how we treat ourselves and others. CAT helps people see these patterns clearly, recognise when they are being enacted, and gradually develop new relational possibilities.
What sessions are usually like
Sessions are collaborative and follow a broadly three-phase structure: Reformulation, Recognition, and Revision
Typical session length: 50 minutes
Frequency: Usually weekly
Time-limited: Yes — commonly 16 sessions (standard) or 24 sessions (for more complex difficulties)
The planned ending is a deliberate and important part of the therapy, often including a “goodbye letter” exchange
Between-session work: Reflective tasks, self-monitoring using rating sheets, practising recognition of patterns
Early sessions focus on building a shared understanding of patterns (reformulation phase)
Middle sessions focus on recognising patterns as they happen in daily life (recognition phase)
Later sessions focus on trying out new responses and preparing for ending (revision phase)
Session profile
Common uses and suitability
What problems it is commonly used for
Who this therapy may suit best
- People interested in understanding why patterns repeat across different situations and relationships
- Those who value both structure and relational depth in therapy
- Individuals with complex or recurrent difficulties where simpler interventions have not been enough
- People who find purely behavioural approaches insufficient to address the relational roots of their difficulties
- Those who appreciate visual and written tools as part of the therapeutic process
- Individuals whose difficulties involve problematic self-to-self relating (e.g., harsh internal critic, self-neglect)
When it may need adapting or may not be suitable
- Acute crisis requiring immediate safety containment before exploratory work
- Severe cognitive impairment that would limit engagement with the reflective and diagrammatic tools
- When a strictly skills-only intervention is required and relational exploration is not indicated
- Active psychosis without stabilisation (though adapted CAT approaches exist for psychosis)
- Very brief intervention needs (fewer than 8 sessions) — CAT’s value lies in its structured but unhurried reformulation process
Where this therapy may not be enough
CAT may not be sufficient for acute symptom management where rapid behavioural stabilisation is the priority (e.g., severe OCD, acute panic disorder). It is not a substitute for medication management in severe mental illness. Where difficulties are purely situational or skills-based without relational maintaining factors, a more targeted intervention may be more appropriate. CAT’s evidence base, while growing, does not yet match the volume of RCTs available for CBT in many specific conditions.
What happens in therapy
Reformulation Letter
Around session 4, your therapist writes you a letter that pulls together what you’ve explored so far — your history, your patterns, and how things make sense. You read it together and adjust it until it feels right. Many people find this deeply validating.
Sequential Diagrammatic Reformulation (SDR)
A visual map or diagram that you and your therapist build together, showing your patterns — how certain roles and responses link together in cycles. Having it on paper makes patterns easier to spot in daily life.
Recognition and Revision
Once you have your reformulation tools, you start noticing your patterns in daily life (recognition), and then practise doing something different (revision). Your therapist supports you in both.
Goodbye Letters
Near the end of therapy, both you and your therapist write goodbye letters reflecting on the therapy journey, what changed, and what’s left to work on. This is a meaningful part of the process.
Reciprocal Role Identification
Together, you identify the main relational patterns from your early life — for example, “critical–criticised” or “care-giving–needy” — and how these show up in your current relationships and in how you treat yourself.
Traps, Dilemmas, and Snags
Three common types of unhelpful pattern: Traps are vicious circles (e.g., feeling low → withdrawing → feeling more alone → feeling lower). Dilemmas are false either/or choices (e.g., “I’m either perfect or worthless”). Snags are ways we sabotage progress (e.g., pulling back just as things improve, as if success isn’t allowed).
The Psychotherapy File
A booklet you’re given at the start of therapy called “An Aid to Understanding Ourselves Better.” It describes common traps, dilemmas, and snags and helps you start recognising your own patterns.
Self-Monitoring and Rating Sheets
Between sessions, you may use simple tracking sheets to notice when your patterns are showing up and which “exit” (new response) you tried.
Evidence Base
Guideline support
CAT is widely used within UK NHS services and has a growing international evidence base. It is not yet included as a standalone NICE guideline recommendation for specific conditions in the way CBT is, but it is recognised in specialist pathways and service-level recommendations, particularly for personality difficulties and complex presentations. NICE CG78 (borderline personality disorder) acknowledges a range of structured psychological therapies, and CAT is frequently offered within NHS personality disorder services. ACAT (the Association for Cognitive Analytic Therapy) maintains a repository of research evidence.
Strength of evidence
Moderate overall; strongest for complex and relational difficulties, personality disorders, and presentations involving recurrent patterns. A meta-analysis of 11 outcome studies (324 patients) found an average effect size of 0.83 (95% CI 0.66–1.00) — a large effect. The Calvert & Kellett (2014) systematic review identified 25 outcome studies including 5 RCTs, with 44% focused on personality disorder. The Hallam et al. (2021) meta-analysis found CAT useful across a range of presentations, with patients particularly appearing to benefit interpersonally. An eight-session CAT showed similar levels of change to CBT for common mental health conditions. The evidence base is smaller than for CBT but is expanding, with particular strengths in areas where standard CBT is less well-evidenced (e.g., complex personality presentations, relational difficulties, dissociation).
Limitations
The RCT evidence base for CAT is still developing, and large-scale multi-site trials are limited. Much of the evidence comes from single-site studies, case series, and practice-based research. Head-to-head comparisons with other therapies are few. Therapist skill, training quality, and relational competence are critical variables that are harder to control in research designs. CAT’s integrative and relational nature makes it less amenable to the component-dismantling research designs that favour manualised symptom-focused therapies.
Evidence claims by condition
CAT helps people with longstanding personality difficulties understand and change repeating patterns in how they relate to themselves and others.
CAT can help with depression, especially when low mood is linked to relational patterns or has not responded to other therapies.
CAT can form part of eating disorder treatment, particularly when the eating disorder is connected to relational patterns.
Resources & Printables
For Adults
Understanding Repeating Patterns
A 2-page guide explaining how CAT understands repeating patterns in thinking, feeling, and relating — including traps, dilemmas, and snags.
Reciprocal Roles Explained
A clear explanation of reciprocal roles — the relational patterns we learn early in life and carry into current relationships.
What to Expect in CAT
A guide to the three phases of CAT (reformulation, recognition, revision), what sessions are like, and how the therapy ends.
Ending and Transition Plan
A reflective tool for the final phase of therapy, supporting the planned ending and consolidating gains.
Pattern Recognition Diary
A self-monitoring tool for tracking when patterns are noticed and what alternative responses (“exits”) were tried.
Traps, Dilemmas, and Snags Worksheet
An interactive worksheet helping clients identify which traps, dilemmas, or snags apply to their patterns.
For Children (6–11)
For Teenagers (12–17)
For Parents & Caregivers
Understanding Relational Cycles
Explains how relational patterns develop and repeat, and how parents can support change without reinforcing unhelpful dynamics.
Supporting Change Without Reinforcing Patterns
Practical guidance for parents on recognising when family dynamics may be maintaining difficulties, and how to respond differently.
For Professionals
SDR Template and Guide
A blank sequential diagrammatic reformulation template with guidance notes on mapping reciprocal roles, procedures, and exits.
Reformulation Letter Structure Guide
A structured guide to writing reformulation letters, including pacing considerations, tone guidance, and examples of collaborative language.
Recognition–Revision Checklist
A clinical checklist for tracking recognition and revision work across sessions, including prompts for therapeutic relationship patterns.
Goodbye Letter Guide
Guidance on writing and exchanging goodbye letters, managing endings, and addressing attachment themes in the final phase.
Contextual CAT: Working with Teams
An introduction to using CAT ideas in staff teams and service contexts — recognising relational dynamics in systems.
Practitioner & Training Notes
Typical professional background
Clinical psychologists, psychiatrists, psychotherapists, and other experienced mental health professionals. CAT requires a solid understanding of relational dynamics, developmental psychology, and integrative working.
Recognised training routes
CAT training is provided through ACAT-accredited programmes across six levels: Level 1 (introductory workshops/CPD), Level 2 (CAT Skills Case Management Certificate — CAT-informed perspective for teams), Level 3 (CAT Foundation Level Certificate — 1-year, primarily for primary care), Level 4 (CAT Practitioner Diploma — 2-year assessed course with minimum 8 supervised therapies, weekly supervision, leading to accreditation as a CAT Therapist/Practitioner), Level 5 (CAT Psychotherapist Advanced Diploma/IRRAPT — 2 additional years, leading to eligibility for UKCP registration as a Cognitive Analytic Psychotherapist), and Level 6 (CAT Supervisor Certificate — competency-based, apprenticeship model). Training includes personal reformulation, intensive supervision, and assessed clinical competencies.
Registration considerations
ACAT (Association for Cognitive Analytic Therapy) is the main UK professional body, a registered charity with approximately 1,000 individual members and an organisational member of UKCP. ACAT maintains accreditation standards, regular practice audits, and a searchable member directory. CAT Psychotherapists may register with UKCP. International CAT associations exist in several countries. NHS England recommends practitioners should also hold registration with a statutory or PSA-accredited register.
Source Registry
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Last evidence review: January 2026. All sources are verified and checked on a scheduled cadence.