Cognitive analytic therapy (CAT) is a time-limited talking therapy that helps you identify repetitive patterns in how you think, feel, and relate to others, then actively work to change them. It blends ideas from cognitive therapy (how thoughts shape behavior) with psychoanalytic theory (how early relationships shape your inner world). A standard course runs 16 to 24 weekly sessions, each lasting about 50 minutes.
What sets CAT apart from other therapies is its collaborative, visual approach. Rather than working primarily through homework exercises or free association, you and your therapist build shared diagrams and written descriptions of the patterns keeping you stuck. The goal is to make unconscious relational habits visible so you can consciously choose different responses.
How CAT Understands Problems
CAT is built on the idea that the ways you learned to cope and relate in early life become templates you carry into adulthood. These templates are called reciprocal roles. They’re pairs of positions people take in relationships, like “controlling to controlled” or “neglecting to neglected.” The top end of each pair is typically learned from a parent or caregiver, while the bottom end reflects the child’s response. Over time, you might find yourself playing either side of the pair in different situations, often without realizing it.
For example, someone who grew up with a highly critical parent might swing between being harshly self-critical (taking on the critical role toward themselves) and feeling small and worthless (staying in the criticized role). They might also become critical of others in close relationships, essentially inviting the people around them to feel the way they once did. These patterns tend to be automatic and self-reinforcing, which is why they’re so hard to break without making them explicit.
CAT also tracks what it calls “procedures,” which are the sequences of thinking, feeling, and acting that play out in response to a situation. A procedure might look like: wanting closeness, then fearing rejection, then withdrawing, then feeling lonely, which loops back to wanting closeness. Mapping these loops helps you see exactly where the cycle could be interrupted.
The Three Phases of Treatment
CAT follows a clear structure across its 16 to 24 sessions, moving through three distinct phases: reformulation, recognition, and revision.
Reformulation
The first few sessions focus on building a shared understanding of your difficulties. You and your therapist explore your history, current problems, and the relational patterns running through both. This understanding gets expressed in two concrete forms. The first is a reformulation letter, written by your therapist in plain language, summarizing how your early experiences connect to your current struggles. The second is a visual map (called a Sequential Diagrammatic Reformulation) that diagrams your procedures and reciprocal roles, drawn collaboratively in session using your own words and images. These aren’t clinical documents handed down to you. They’re built together, and you should recognize yourself in them.
Recognition
Once the patterns are mapped, the work shifts to spotting them in real time. You start noticing when a familiar procedure is playing out in your daily life, in your relationships, and in the therapy room itself. This is a distinctive feature of CAT: the relationship between you and your therapist becomes live material. If you tend to comply with authority figures while silently resenting them, that pattern will likely surface in sessions. The therapist’s job is to pause and name what’s happening rather than unconsciously playing along with the role you’re inviting them into. This shared noticing builds your ability to catch patterns earlier and earlier.
Revision
The final phase is about trying new ways of responding. In CAT language, these alternative responses are called “exits,” meaning points on your map where you can step off the familiar loop and do something different. If your usual pattern is to avoid conflict and then build up resentment, an exit might involve expressing a need directly in a low-stakes situation. The therapist supports you in experimenting with these exits both inside and outside sessions. Near the end of therapy, you and your therapist exchange goodbye letters reflecting on the work, what changed, and what to watch for going forward.
What CAT Treats
CAT was originally developed for depression and personality-related difficulties, and it remains most commonly associated with borderline personality disorder, where its focus on relational patterns is a natural fit. It has since been applied to a broader range of conditions. Pilot studies have tested CAT for bipolar disorder in the UK and for early psychosis combined with personality difficulties in Australia. It’s also been adapted for eating disorders, with brief CAT-informed approaches used specifically for young people.
CAT may be a particularly good option when cognitive behavioral therapy (CBT) hasn’t worked, when interpersonal or personality-related difficulties are central to the problem, or when you simply prefer a therapy that explores relational history rather than focusing primarily on symptom management. For psychosis specifically, the evidence base is still developing, but interest in CAT as an alternative to CBT for people who don’t respond to it continues to grow.
What the Evidence Shows
The research base for CAT is smaller than for therapies like CBT, but the existing evidence is encouraging. In a guided self-help adaptation for depression, all patients who started treatment completed the full six sessions (with only one dropping out before beginning), and 7 out of 10 completers achieved reliable recovery at follow-up. An earlier pilot of the same approach found 6 out of 10 patients in reliable recovery. These are small studies, and more controlled trials are needed, but the completion rates are notably high, suggesting people find the approach engaging and tolerable.
The high engagement likely connects to something fundamental about how CAT works. Because the reformulation is genuinely collaborative, with your own words on the map and a letter that reads like it was written by someone who truly listened, people tend to feel understood early in treatment. That sense of being seen can be especially powerful for people whose previous therapy experiences felt rigid or impersonal.
How CAT Differs From CBT
Both CAT and CBT are structured, time-limited therapies. But they focus on different layers of experience. CBT targets specific thoughts and behaviors maintaining a current problem: identifying cognitive distortions, testing beliefs through behavioral experiments, building coping skills. It’s practical and present-focused.
CAT goes a level deeper into relational history. It asks not just “what are you thinking?” but “where did you learn to think and relate this way?” The visual mapping of patterns is unique to CAT and gives you a tool you can literally look at between sessions. CAT also pays close attention to the therapy relationship itself as a place where old patterns show up and can be reworked, something CBT doesn’t emphasize to the same degree.
Neither approach is universally better. CBT has a much larger evidence base and is more widely available. CAT tends to suit people whose difficulties are relational in nature, who want to understand the origins of their patterns, or who’ve tried CBT without lasting benefit.
Finding a CAT Therapist
In the UK, CAT therapists are accredited through the Association for Cognitive Analytic Therapy (ACAT). Full accreditation requires a two-year training program that includes clinical experience and assessment. Therapists who complete only the first foundation year can offer CAT under supervision within NHS Talking Therapies services. Fully accredited practitioners can offer CAT independently to individuals, and with additional experience and supervision, to couples and groups.
All ACAT-accredited therapists are required to remain in clinical supervision for their CAT work and follow the ACAT Code of Ethics and Practice. If you’re seeking CAT privately, checking for ACAT accreditation is the most reliable way to verify that someone has completed recognized training. CAT is more widely available in the UK than in most other countries, though training programs exist in several places internationally, including India and Australia.