Cognitive analytic therapy (CAT)

What is cognitive analytic therapy?

Cognitive analytic therapy (CAT) is an integrative, time-limited therapy developed by Anthony Ryle in the 1980s within the NHS. It brings together ideas from cognitive and psychodynamic traditions to offer a practical, collaborative approach to understanding and changing longstanding patterns of thinking, feeling and relating.

CAT is built on the principle that many of our current difficulties are rooted in patterns, called reciprocal roles, that we learned through early relationships. These patterns were often adaptive at the time, helping us cope with the environment we grew up in, but they can become rigid and unhelpful in adult life. For example, someone who learned to be compliant and self-sacrificing to maintain a relationship with a critical caregiver may find themselves repeating this pattern with partners, friends or colleagues, at the cost of their own needs.

A distinctive feature of CAT is the use of written and diagrammatic tools. Together with your psychologist, you will create a shared reformulation, a written account of how your difficulties developed, and a sequential diagrammatic reformulation (SDR), a visual map of your patterns. These tools become a shared reference point throughout therapy, helping you recognise your patterns as they play out in real time and experiment with doing things differently.

What makes CAT distinctive among relational therapies is the emphasis on making patterns visible and nameable. Many people go through life sensing that something keeps going wrong in the same way, but without a clear framework for understanding it. The reformulation tools give you that framework. They turn vague feelings of stuckness into something concrete that you can observe, discuss and ultimately change.

CAT also recognises that we do not simply have one fixed way of relating. Most people move between different relational positions, sometimes in rapid succession. For example, you might swing between feeling completely responsible for others and suddenly withdrawing when the pressure becomes too much. CAT maps these shifts and helps you understand the internal logic that drives them, which is the first step towards finding a more balanced position.

Central to the CAT model is the concept of problematic patterns, which are described using three specific terms. A trap is a pattern in which an unhelpful assumption leads to behaviour that reinforces the original assumption - for instance, believing “I must please everyone to be liked” leads to over-giving, which leads to exhaustion and resentment, which confirms the belief that relationships are draining. A dilemma is a false either/or choice, such as “either I put others first and lose myself, or I put myself first and end up alone.” A snag is a pattern in which progress towards a goal is unconsciously undermined, often because change itself feels threatening or disloyal - for example, someone who begins to assert their needs but then pulls back because they feel guilty about no longer being the “easy-going” one. Naming these patterns precisely is one of the reasons CAT can produce change relatively quickly.

Who is CAT suitable for?

CAT is suitable for a wide range of people, but it is particularly well matched to those whose difficulties are relational in nature - connected to the ways they relate to themselves and to others. If you notice that your struggles with depression, anxiety or low self-esteem seem to follow recurring themes, or if similar difficulties keep appearing across different relationships and situations, CAT may be especially helpful.

We often recommend CAT for people who feel that their difficulties go deeper than specific symptoms. If you have tried more symptom-focused approaches and found them helpful in the short term but not lasting, CAT’s emphasis on understanding the underlying relational patterns can offer a more durable form of change. It is also a strong choice for people who value collaboration and want to take an active role in their therapy - the reformulation tools give you a framework that you genuinely co-create with your psychologist, rather than simply receiving.

CAT is widely used for difficulties with emotion regulation and relationships, where it is one of the recommended structured therapies. It is also well suited to people dealing with complex trauma, difficulties with emotional regulation, self-harm, eating difficulties, and interpersonal problems at work or in intimate relationships.

That said, CAT is not the right fit for everyone. Because it is time-limited and relationally focused, it may be less suitable for difficulties that are primarily physiological in nature or for people who need open-ended long-term support. Your psychologist will discuss this with you during your initial sessions and will always be transparent about whether CAT is the best approach for your particular situation.

When it helps

CAT is particularly well suited to relational and interpersonal difficulties, including:

• Recurring patterns in relationships
• Difficulties with emotion regulation and relationships
• Depression linked to interpersonal patterns
• Anxiety rooted in relational dynamics
• Low self-esteem and people-pleasing
• Difficulties with boundaries
• Self-harm and self-destructive behaviours
• Eating difficulties
• Complex trauma and childhood adversity
• Adjustment to loss, transitions or chronic illness

CAT is especially helpful when you notice that you keep ending up in the same kinds of difficult situations, or when you feel caught between extreme positions, such as either putting everyone else first or withdrawing completely. It is also a strong choice if you have found previous therapies helpful in the moment but struggled to maintain change, as the visual tools and structured approach give you something concrete to take forward.

People dealing with grief or major life transitions can also benefit from CAT, particularly when the loss activates longstanding relational patterns. For example, bereavement might trigger feelings of abandonment that connect to much earlier experiences, and CAT is well equipped to help you understand these links.

What to expect

CAT is a time-limited therapy, typically lasting 16 or 24 sessions. This structure is intentional, as having a clear ending from the outset can itself be therapeutic, particularly for people who struggle with endings or fear abandonment.

The reformulation phase (sessions 1 to 4)

The first few sessions focus on exploration and reformulation. You and your psychologist will work together to understand your history, identify your key relational patterns and create your written and diagrammatic tools. This process is collaborative and you will be an active partner in shaping the reformulation.

Your psychologist will ask you about your early relationships, your current difficulties and the patterns you notice repeating in your life. Together, you will identify your reciprocal roles, the paired positions you tend to take up in relationships, such as “criticising to criticised” or “caring for others to neglecting self.” Around session four or five, your psychologist will share a reformulation letter, a written account of how your difficulties developed, written directly to you. This is a powerful moment in therapy for many people, as it brings together your story in a way that makes sense of patterns you may have struggled with for years.

The SDR, your diagrammatic map, is usually developed alongside the letter. It provides a visual overview of your patterns, showing how different roles and coping strategies connect and how they keep you stuck in familiar loops. Clients often describe the diagram as a revelation, making visible something they had always felt but never been able to articulate.

The recognition and revision phase (sessions 5 to 12 or 18)

The middle phase focuses on recognition and revision. Using your reformulation as a guide, you will practise noticing your patterns as they arise in daily life, including within the therapy relationship itself, and begin experimenting with new ways of responding. Your psychologist will actively use the therapeutic relationship to support this work.

Between sessions, you may use rating sheets, diaries or simply your own awareness to track when your patterns appear. The goal is not to eliminate these patterns overnight but to create a gap between the trigger and your response, a space in which you can choose to do something different. Over time, what starts as effortful recognition becomes more automatic.

Your psychologist will also pay close attention to how your relational patterns show up in the room. For example, if you tend to take a compliant role to avoid conflict, this might emerge as always agreeing with your psychologist’s suggestions. Naming these moments, without judgement, creates a live opportunity for change.

The ending phase (final 3 to 4 sessions)

The final sessions address the ending of therapy, reviewing your progress and preparing you to continue the work independently. You will each write a goodbye letter reflecting on the therapy, which many people find a meaningful part of the process. The ending is treated as a significant event, particularly because how you manage endings is often directly connected to the patterns that brought you to therapy.

The tools used in CAT

One of the features that sets cognitive analytic therapy apart from other relational therapies is its use of specific collaborative tools. These are not worksheets or exercises in the conventional sense - they are living documents that you and your psychologist create together and return to throughout the therapy.

The reformulation letter is typically shared by your psychologist around session four or five. It is a carefully written letter addressed to you that tells the story of how your current difficulties developed, drawing on what you have shared about your early experiences and present-day patterns. The letter is written in a compassionate, non-judgemental tone and aims to make sense of your difficulties in a way that feels both accurate and validating. Many people describe reading their reformulation letter as a turning point - the moment when their struggles begin to feel understandable rather than inexplicable.

The sequential diagrammatic reformulation (SDR) is a visual map of your relational patterns. It shows the reciprocal roles you tend to occupy, the traps, dilemmas and snags that keep you stuck, and the connections between them. The SDR is developed collaboratively, usually alongside the reformulation letter, and it becomes a reference point for the rest of therapy. You and your psychologist will return to the diagram regularly, using it to track where you are in your patterns and to identify moments when you have the opportunity to respond differently.

Goodbye letters are exchanged in the final sessions. Both you and your psychologist write a letter reflecting on what has happened in the therapy - what has changed, what remains, and what you are taking forward. The goodbye letter process is not simply a closing ritual; it is a therapeutic intervention in its own right. For many people, endings have been difficult or poorly managed in the past, and the structured, mutual ending of CAT provides an opportunity to experience separation in a healthier way.

Together, these tools give CAT a concreteness that many people find reassuring. Rather than therapy feeling like an open-ended conversation, you have tangible reference points that anchor the work and that you can continue to use long after therapy has ended.

How CAT differs from CBT

This is one of the questions we are asked most often, and it is an important one. Both cognitive analytic therapy and cognitive behavioural therapy (CBT) are evidence-based, structured approaches, but they differ in focus, method and scope.

CBT is primarily concerned with the relationship between thoughts, feelings and behaviours in the present. It works by identifying unhelpful thinking patterns and testing them through behavioural experiments and structured techniques. It is highly effective for many specific conditions, including anxiety and depression, and is often the first-line recommendation for these difficulties.

CAT, by contrast, takes a broader and more relational view. Rather than focusing on specific thought patterns, it asks how your way of relating to yourself and others developed, and how those relational patterns maintain your current difficulties. Where CBT might work on a specific belief such as “I am going to fail,” CAT would explore the relational context in which that belief was formed - perhaps a childhood in which approval was conditional on achievement - and map out the wider pattern of roles and responses that flows from it.

The tools are also different. CBT uses thought records, behavioural experiments and graded exposure. CAT uses reformulation letters, sequential diagrammatic reformulation and goodbye letters. Both sets of tools are practical and collaborative, but they serve different purposes. CBT tools are designed to challenge and modify specific cognitions; CAT tools are designed to make relational patterns visible so that you can recognise and revise them.

Neither approach is inherently better than the other. The right choice depends on the nature of your difficulties and your goals for therapy. If you are unsure which would suit you best, we are happy to discuss this when you get in touch.

The evidence for CAT

CAT has a solid and growing evidence base, with research supporting its effectiveness across a range of presentations. The approach was originally developed and evaluated within the NHS, and it continues to be widely used in NHS mental health services across the UK.

Randomised controlled trials have demonstrated the effectiveness of CAT for people who experience longstanding difficulties with emotions and relationships (what services have traditionally diagnosed as ‘borderline personality disorder’), where it has been shown to reduce self-harm, improve interpersonal functioning and produce clinically meaningful symptom change. CAT has also been evaluated for depression, eating disorders and complex presentations involving multiple overlapping difficulties.

NICE recognises CAT within its guidance for these difficulties (the guidance it titles ‘borderline personality disorder’), listing it as a structured psychological therapy that should be considered. The approach is also recommended in various NHS trust clinical guidelines for complex presentations where purely symptom-focused therapies may be insufficient.

One of the strengths of the CAT evidence base is its focus on real-world clinical settings. Much of the research has been conducted in routine NHS practice with the kinds of complex presentations that clinicians see every day, rather than in highly controlled research environments. This gives confidence that the outcomes translate well to everyday clinical work.

Research on the specific mechanisms of CAT, particularly the reformulation tools, suggests that the process of creating a shared understanding of your patterns is itself therapeutic. Studies have found that clients who develop a clear and personally meaningful reformulation show greater engagement with therapy and better outcomes.

CAT at The Online Psychologists

At The Online Psychologists, CAT is delivered by HCPC-registered clinical and counselling psychologists with specific training in cognitive analytic therapy. Our psychologists are experienced in using the reformulation tools in an online setting and understand how to create a strong therapeutic relationship through video.

The collaborative, tool-based nature of CAT translates particularly well to online delivery. Screen sharing allows your psychologist to develop the SDR diagram with you in real time, and many clients find this even more engaging than working on paper, as the diagram can be easily edited, refined and shared digitally. Reformulation letters and other written materials are shared securely between sessions, giving you time to read and reflect on them at your own pace.

When you get in touch, we begin with a careful matching process. We consider your presenting difficulties, your goals for therapy and any preferences you have about your psychologist. If you are unsure whether CAT is the right approach for you, your psychologist will discuss this with you in the initial sessions and may suggest an alternative if a different therapy would be a better fit.

Sessions are held weekly and last 50 minutes. Most courses of CAT are either 16 or 24 sessions, with 24 sessions typically recommended for more complex presentations such as complex emotional difficulties or longstanding relational trauma. The time-limited structure is a core feature of the model, not a shortcut, and the ending is built into the therapy from the very first session.

CAT at TOP may be a good fit if you recognise yourself as someone who keeps repeating patterns in relationships, who struggles with boundaries, or who finds yourself caught between extremes, such as caring too much about what others think versus shutting people out entirely. It is also well suited for people experiencing stress or burnout where relational patterns at work are a significant contributing factor.

If you think cognitive analytic therapy might be right for you, or if you would like to discuss whether CAT is a good fit for your situation, please get in touch. We offer a brief initial conversation to help you understand your options and find the right psychologist for your needs.

Frequently asked questions

How is CAT different from CBT? CBT focuses primarily on the relationship between thoughts, feelings and behaviours in the here and now, often targeting specific symptoms. CAT takes a broader view, looking at the relational patterns that underpin your difficulties and how these were shaped by your early experiences. CAT also uses distinctive tools, the reformulation letter and diagram, which give you a visual and written framework for understanding your patterns. Both approaches are evidence-based, and the right choice depends on the nature of your difficulties.

Is 16 sessions enough to make a real difference? For many people, yes. The time-limited structure of CAT is designed to create focus and momentum, not to rush you. Research shows that meaningful change can occur within 16 sessions, particularly when the reformulation tools help you quickly identify and begin working with your key patterns. For more complex difficulties, 24 sessions is available. The ending itself is a therapeutic part of the process, giving you a planned experience of separation that you can manage differently from past endings.

Will I have to talk a lot about my childhood? CAT does explore your early experiences, but it does so in the service of understanding your present-day patterns, not for its own sake. The focus is always on how the past shows up in the present and what you can do differently now. Your psychologist will guide this exploration at a pace that works for you and will not push you to discuss anything you are not ready to explore.

Can CAT help with anxiety as well as depression? Yes. While CAT is well known for its work with depression and longstanding difficulties in emotions and relationships, it is also effective for anxiety, particularly when the anxiety is rooted in relational patterns. For example, social anxiety often connects to internalised expectations about being judged or rejected, which are exactly the kinds of reciprocal roles that CAT is designed to address.

What is the map or diagram used in cognitive analytic therapy? The sequential diagrammatic reformulation (SDR) is a visual map created collaboratively by you and your psychologist, typically around session four or five. It plots the relational patterns you tend to repeat, the roles you take up in relationships, and the cycles that keep you stuck. The SDR becomes a shared reference point throughout therapy, helping you recognise your patterns as they appear in daily life and identify moments when you can respond differently. Many clients describe seeing their SDR for the first time as a turning point in their therapy.