What is Cognitive Analytic Therapy?

Cognitive analytic therapy, also known as CAT, is a talking therapy that mainly focuses on the way we relate to ourselves and to other people.

It 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, or
• doing things that are harmful or self-defeating as a way to stop feeling overwhelmed by strong feelings

It is based on the idea that as children we cope with difficult situations we find ourselves in by developing strategies to manage them. These strategies, or patterns of how we think, feel and act, come about to help us cope with difficulties.  They can be necessary for our emotional survival earlier in our life.

However, if we continue to use them even when they are no longer needed, these patterns may lead to difficulties. We may become stuck in these patterns and come to feel they are now problems themselves.

For example, if you had learned in your childhood that you only received love and care by pleasing others, you might believe that ‘only if I do what others want will I be liked’  This puts you in a trap of pleasing others, and can lead to you feeling used and abused. Only when you realise you have got used to being in this trap you can start to notice how often it catches you out.  Then you can begin to change what you do – for example, by learning other more useful ways of standing up for yourself and relating to others.

CAT shows you the way to change your learned attitudes and beliefs about yourself and others, and helps you focus on ways to make better choices.

How can CAT help me?

CAT involves your therapist working alongside you to work out together what issues you would like help with, where they came from, and how they could change so that you can be happier and live more how you would like to live. No two people are the same and difficulties start for different reasons. CAT is tailored to your individual needs and goals, and helps you make sense of your own story in your own circumstances.

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

• clarify which ones are helpful or unhelpful
• understand the effect they are having
• make sense of how they developed and why you needed them
• start to develop new more helpful patterns, and
• develop a better relationship with yourself and others

The aim is to reduce the distress you experience in your relationships with others, and with yourself.

What preparation is needed?

You do not need to prepare for CAT. However, it may help to think through what you feel your main difficulties are and what you hope to gain from therapy. You also need to be prepared to make a commitment to attend regular weekly appointments.

What happens at the first appointment?

The therapist will ask you why you are seeking therapy and talk to you about what this involves. This session gives you the opportunity to:

• find out if CAT is likely to be helpful for you
• decide if you are happy to work with the therapist
• ask any questions you may have about the therapy

What does the therapy involve?

Early sessions

Together you and your therapist will gradually build up a picture of your difficulties. CAT has a strong focus on the therapist working jointly alongside you so that your voice and opinion is heard at every step of the way.

Early therapy sessions will involve telling and hearing your story. The therapist does not need to know every detail. What you share will be paced according to what you feel able to manage.

With your therapist you will begin to piece together patterns that keep you feeling stuck in negative cycles of emotions, repeating things you don’t want to over and over again. You will also be helped to think about how these patterns developed.

You may be asked to complete a questionnaire called the Psychotherapy File. This gives examples of patterns and states of mind people often describe.

You may also agree that it would be helpful to do some tasks between sessions, such as monitoring your mood or behaviour patterns. This may help you spot patterns in relationships with yourself and other people in your life. Sometimes the same patterns can arise in therapy, between you and your therapist. He or she will be interested in noticing when this happens and trying to make sense of it together.

Agreeing what to work on

Once you and your therapist have identified your patterns and how they came about, it is helpful to put together a letter which summarises what you’ve found out, and helps you keep track of how you plan to change things together. Your therapist might draft a letter to you, or you might choose to write it together. The letter will describe your story and your patterns, to help you choose what you want to focus on in the therapy.

Your diagram or map

Your therapist may also draw a diagram with you as a visual summary of the patterns to be clear about the patterns you are working on and for you recognise when you are in them.

The middle phase of CAT therapy

From this point CAT gives you the space to begin to focus on two or three patterns you want to change. Monitoring between sessions and exploring things further during sessions helps you notice when you are using these patterns.

As you become better at spotting patterns it can become easier to think about new more helpful ways to be. Your therapist supports you in discovering and trying out new possibilities for change. You and your therapist will work together to overcome obstacles which often get in the way of change.

Ending CAT therapy

CAT is a time-limited therapy and the therapist will help you keep the idea of the ending in mind, even from the start of your meetings. Towards the end of therapy this will be something that you and your therapist will talk about more.

As you come to the end of your meetings, you and your therapist will each write an ending letter. This gives you both a chance to reflect on the therapy, what you can take away from it, how you feel about this ending, and the future.

How long does therapy last?

CAT is usually offered for 8, 16 or 24 sessions. You and your therapist will discuss how many sessions you are being offered at the beginning of your therapy. Appointments are usually weekly and last for between 50 and 60 minutes.

What follow-up is needed?

You will usually be offered a follow-up appointment two to three months after your last session. This will give you the chance to review how things have gone for you after therapy has finished. If you have had a 24 session CAT, you may be offered a few more follow up sessions in order to ease out of the therapy a little more slowly.

What are the benefits?

CAT can’t undo painful experiences in the past that have led to difficulties. But it can help you feel you have more control over patterns of self-care, self-harm and relationships with others. It can also help you to make positive changes for the future.

What are the risks?

There can be risks, and as with any talking therapy.  For example, focusing on your problems may temporarily make you feel worse before you feel better.  Your therapist will help you make sense of why this is. It might also be unsettling if you decide to make changes in your relationships that are better for you, but might be confusing or challenging for people close to you. Therapy can be an intense experience and the relationship you make with your therapist can feel very important. Coming to the end of therapy can stir up strong feelings and this is why CAT gives the ending a lot of care and attention.

What if I feel things are not going well or the therapy does not suit me?

You are always free to leave CAT therapy if you don’t feel it is working well for you. Your therapist will encourage you to say how it’s going, so they can adapt what they do to make it most helpful.

If you have problems with the therapy, it’s always good to tell your therapist.  Then together you can work out with you what needs to change.  This can give you and your therapist a chance to try to work out what’s causing the problem, and whether this links to any of the patterns which are a focus for your therapy. Sometimes by talking and thinking together about problems you can find a way through them.

What ethical standards can I expect in CAT therapy?

Accredited CAT therapists and trainees n CAT who are members of ACAT comply with an ethical code of practice in addition to their own professional code of conduct. You can read ACAT’s ethical code of practice by clicking on this link

How do I make a complaint about CAT therapy?

If your therapist behaves in a way that you feel is harmful, damaging or unethical, you can raise this with the service providing your therapy. You can also raise any concerns or complaints with ACAT by using the form available at this link.

This information drew upon material produced by Kate Freshwater of Tees, Esk and Wear Valleys NHS Trust, also published via TEWV’s Recovery College Online.  It can also be accessed through University College London’s Competence Framework for Cognitive Analytic Therapy (CAT) at this link.

Thanks are extended to many people who contributed views and feedback in its development.

This information is reproduced on the University College London website as part of information linked to the Competence Framework for Cognitive Analytic Therapy (CAT) .

You can also download a copy of this information here: 4 What is CAT service user document April 2022

What is Cognitive Analytic Therapy? by CAT Competences Expert Reference Group, ACAT Public Engagement Team & others CC BY-NC 4.0