Cognitive analytic therapy

1. Introduction

Version followed: standard individual 16-session CAT (Ryle 1990; Ryle & Kerr 2002) as set out in the ACAT/UCL CAT competence framework (Parry, Bennett, Roth & Kellett 2021), with the 8-session IAPT form (White & Hepple 2020) and the 24-session form for complex presentations noted where they differ. Ryle's books themselves are not drawn on; their content comes through ACAT's journal Reformulation, the competence framework and a published review [uncertain where noted].

Cognitive analytic therapy (CAT) is a time-limited, relational, integrative psychotherapy developed in the UK by Anthony Ryle, a general practitioner and analytically trained psychotherapist, for use in the NHS. It grew from Ryle's 1970s repertory-grid research on therapy transcripts and his 1979 proposal for a shorter, more active therapy that joins cognitive methods (goal setting, Socratic questioning) with analytic attention to relationships; later influences are Kelly's personal construct theory, object relations theory, Vygotsky (scaffolding, zone of proximal development) and Bakhtin (dialogism) [source: Wikipedia CAT entry; Parry et al. 2021].

Core idea of change: early relationships are internalised as reciprocal roles (paired positions such as criticising–criticised, neglecting–neglected) and the habitual procedures that enact them. These began as survival strategies but persist unrevised because their outcomes seem to confirm them (traps, dilemmas, snags). Therapy jointly writes these patterns down (a letter and a diagram), helps the client recognise them as they happen, including inside the therapy relationship, and then revise them by building personally meaningful exits, all within a fixed number of sessions whose ending is itself worked with [source: Blunden 1993; Parry et al. 2021; White & Hepple 2020].

2. Framework

Format. Individual, weekly, time-limited; the number of sessions is agreed at the start. 16 sessions is the usual contract; 24 sessions (with three or more follow-ups) for more complex clients, e.g. personality disorder; 8-session brief forms are used in primary care/IAPT; 1, 4 and 12-session forms are also reported [source: White & Hepple 2020; Blunden 1993; Wikipedia]. Homework is usually set between sessions [source: Blunden 1993].

Phases (the competence framework notes phases "bleed over") [source: Parry et al. 2021]:

Follow-up. Sources differ: one session at about three months (Blunden 1993; White & Hepple 2020 for 16 sessions), or one at one month and one at three months (Wikipedia); usually none in the 8-session IAPT form [uncertain: follow the convention of your service and ACAT supervisor].

8-session IAPT variant [source: White & Hepple 2020]: sessions 1–3 alliance, history, target problems, tentative procedures, Psychotherapy File; session 4 reciprocal-role diagram introduced; sessions 5–7 map completed, recognition, first exits, client invited to bring a goodbye letter; session 8 goodbye letters exchanged. No early reformulation letter: the narrative moves into the therapist's goodbye letter. Another 8-session form (Sandhu et al. 2017) allots reformulation 2, recognition 3, revision 2, ending 1 session.

Suitability. The competence framework lists factors weighing against individual CAT: acute psychotic disorder, active continuous substance misuse, multiple prescribed medications, serious acute physical illness, and active risk of violence; suitability also requires informed consent and the therapist knowing the limits of their competence [source: Parry et al. 2021]. CAT has been applied in depression, panic, eating disorders, self-harm, dissociative and personality disorders, offenders and medical settings [source: Wikipedia].

3. Guiding principles

• Time-limited by design. The fixed ending is a therapeutic tool; name it from session 1 and every session [source: Parry et al. 2021; White & Hepple 2020].
• Collaboration: "doing with" rather than "doing to". Every formulation is offered tentatively and revised with the client [source: White & Hepple 2020].
• Reformulate before you change. All change techniques are chosen and explained through the shared reformulation [source: Parry et al. 2021].
• Relational, reciprocal-role lens. Look for role pairs (other-to-self, self-to-other, self-to-self) behind symptoms; roles are inferred from what the person does [source: White & Hepple 2020; Parry et al. 2021].
• Procedures as survival strategies. Frame patterns as once-necessary coping that now defeats the client's aims; this lowers shame [source: White & Hepple 2020; Parry et al. 2021].
• Work in the zone of proximal development (ZPD). Pitch each task just beyond what the client can do alone; too much risks shame, too little fosters dependence [source: Parry et al. 2021].
• Pace disclosure to the client. History is gathered at the client's pace [source: White & Hepple 2020].
• Expect enactments in the room and use them. The client's roles will be re-enacted with you; name and learn from them rather than act them out [source: White & Hepple 2020; Parry et al. 2021].
• Your feelings are data. Feelings the client elicits in you suggest which role you are being invited into [source: Parry et al. 2021; Sandhu et al. 2017].
• Hold task and process together. Judge when to stay with tasks (letter, map, homework) and when to shift to what is happening between you [source: Parry et al. 2021].
• Know which phase you are in. Keep the salient phase in mind each session [source: Parry et al. 2021].
• Written and drawn tools are shared property. Letters and maps are written for and with the client, who keeps copies [source: Parry et al. 2021].
• Exits are personal. Revision builds idiosyncratic, client-meaningful alternatives, not generic skills [source: Sandhu et al. 2017].
• Avoid harm. Monitor for therapy causing harm and manage risk throughout [source: Parry et al. 2021].
• Use supervision and measures. CAT is supervised; outcome measures guide therapy and can reveal re-enactments [source: Parry et al. 2021; White & Hepple 2020].

4. Intervention inventory

Interventions are listed in roughly the order they appear in a 16-session course. Example language is illustrative unless quoted and cited. Sources for this section: Parry et al. 2021 (competence framework), Blunden 1993, White & Hepple 2020, Sandhu et al. 2017, Ryle 2003, Hubbuck 2008, Marks 2003 (review of Ryle & Kerr 2002); finer procedural detail not found in these is marked [synthesis] or [uncertain].

4.1 Setting up therapy and agreeing the contract

• Purpose / when: Session 1. Establish a safe, informed, time-limited frame and a collaborative stance [source: Parry et al. 2021; White & Hepple 2020].
• Steps: (1) Complete practical tasks: consent, GP and key contacts, medication, risk documentation, introduction to outcome measures [source: White & Hepple 2020]. (2) Explain the relational CAT model briefly and that therapy is joint work. (3) Agree the number of sessions and give the date of the final session [source: Wikipedia; Parry et al. 2021]. (4) Explain the tools to come (letter, map, homework, goodbye letters, follow-up) [synthesis on order of explanation]. (5) Ask about hopes and fears for therapy [source: White & Hepple 2020].
• Example language (illustrative): "We have 16 sessions, ending on [date]. In the first few we'll try to understand together how the problems you've brought hang together, and I'll write that down for you as a letter we can correct together."
• Watch for: early signs of the client's role patterns in how they take up the contract (over-compliance, testing, dismissing); note them as possible procedures to offer tentatively later [source: White & Hepple 2020; synthesis].

4.2 Assessment, suitability and risk

• Purpose / when: Sessions 1–2, then ongoing. Decide whether individual CAT is safe and suitable; assess self-harm and other risk [source: Parry et al. 2021].
• Steps: (1) Standard risk assessment for self-harm and suicide, harm to others, and safeguarding [source: Parry et al. 2021 (generic competence); detail is standard practice, synthesis]. (2) Check the factors the framework lists against suitability: acute psychosis, active continuous substance misuse, multiple prescribed medications, serious acute physical illness, active risk of violence [source: Parry et al. 2021]. (3) Weigh your own competence and supervision, and the client's informed consent [source: Parry et al. 2021]. (4) Choose contract length (8/16/24) by complexity [source: White & Hepple 2020]. (5) If dissociative or borderline features are present, plan a longer contract and a self-states approach (4.10) [synthesis drawing on Ryle 2003; Hubbuck 2008].
• Example language (illustrative): "Before we agree to work this way, I need to understand how safe things are for you at the moment, including any thoughts of harming yourself."
• Watch for: risk rising as patterns are named or as the ending approaches; keep risk on the agenda throughout [synthesis].

4.3 Agreeing target problems (TPs)

• Purpose / when: Sessions 1–3. Define, in the client's own terms, what the therapy is for [source: White & Hepple 2020; Blunden 1993].
• Steps: (1) Ask what the client most wants to change. (2) Phrase each problem in their words (White & Hepple's examples: "my anger", "I feel lost"), not only as diagnoses [source: White & Hepple 2020]. (3) Keep the list short (usually two to four) [synthesis/uncertain on number]. (4) These later head the TPP list in the letter [source: Blunden 1993].
• Example language (illustrative): "If therapy went well, what would be different? Let's name the two or three things that matter most, in your words."
• Watch for: target problems phrased only as other people's behaviour; gently reframe toward the client's part in the pattern [synthesis].

4.4 The Psychotherapy File

• Purpose / when: Sessions 1–3, in session or as homework. A self-help leaflet describing common traps, dilemmas, snags and unstable states, which the client marks as applying or not; it seeds the TPPs [source: Blunden 1993; Parry et al. 2021; White & Hepple 2020].
• Concepts (paraphrased from Blunden 1993): Trap: a negative belief leads to action whose outcome seems to confirm the belief. Dilemma: options narrowed to two, both costly (a false either/or). Snag: an aim is abandoned because of real or anticipated negative consequences, following an internal rule.
• Steps: (1) Introduce it as a way of finding patterns, not a test. (2) Ask the client to read it at home and mark what fits. (3) Review it together next session, asking for a recent example of each marked pattern [synthesis on review method]. (4) Translate marked items into the client's own wording for the letter. Do not reproduce the File; obtain it via ACAT training.
• Example language (illustrative): "This describes some patterns people often get stuck in. Mark any that sound like you, and we'll look for real examples together."
• Watch for: avoidance of the File (not done, lost, done perfunctorily). The framework treats this as a moment to judge whether to shift from task to relational process [source: Parry et al. 2021]. Marking every item may reflect a placating role [synthesis].

4.5 Life chart and family tree (genogram)

• Purpose / when: Sessions 1–3. Gather the developmental and relational history from which reciprocal roles are inferred [source: Parry et al. 2021; White & Hepple 2020].
• Steps: (1) Draw a family tree of early relationships with the client [source: White & Hepple 2020]. (2) Build a life chart of key events by age [source: Parry et al. 2021; layout is synthesis]. (3) Ask how each key person treated the client and how the client learned to cope. (4) Note recurrent relational themes and how the client tells the story [source: Parry et al. 2021].
• Example language (illustrative): "What was it like to be a child in that house? When things went wrong, what did you learn to do to get through?"
• Watch for: distress during history taking; slow down within the client's tolerance [source: White & Hepple 2020 on pacing].

4.6 Identifying reciprocal roles and target problem procedures (TPPs)

• Purpose / when: Sessions 2–5. Link past experiences to present problems via role pairs and the procedures that maintain the TPs [source: Blunden 1993; Parry et al. 2021].
• Steps: (1) From history, the File and current examples, hypothesise core role pairs (e.g. neglecting–neglected, abusing–abused, criticising–criticised) [source: White & Hepple 2020]. (2) Trace each role in three directions: how others treated me, how I treat others, how I treat myself [source: White & Hepple 2020]. (3) For each TP, describe the TPP as a sequence: situation and appraisal, feeling, aim, action, consequence, re-appraisal (the procedural sequence) [source: Parry et al. 2021; Blunden 1993]. (4) Classify as trap, dilemma or snag where it fits. (5) Offer hypotheses tentatively and revise with the client [source: White & Hepple 2020].
• Example language (illustrative): "It sounds as if you learned that needing anything got you criticised, so you stopped asking. Now when you need help you try to manage alone, end up exhausted, and that seems to prove no one will help. Does that fit?"
• Watch for: the client recognising themselves (relief, "that's it") versus polite agreement; ask for an example from this week to test fit [synthesis].

4.7 Using your own feelings and in-session enactments in formulation

• Purpose / when: Throughout, especially early. Feelings the client evokes in you, and patterns enacted between you, show the role repertoire directly [source: Parry et al. 2021; White & Hepple 2020].
• Steps: (1) After each session note what you felt pulled to do (rescue, criticise, withdraw, placate). (2) Ask which reciprocal role that pull fits. (3) Take it to supervision. (4) Use it as a tentative hypothesis in the formulation, not as a disclosure in itself [synthesis on steps 1–4].
• Watch for: acting the role instead of noticing it (e.g. becoming critical with a client who expects criticism) [source: White & Hepple 2020].

4.8 The reformulation letter

• Purpose / when: Read to the client at session 4 in standard 16-session CAT; discussed and revised at session 5 [source: Blunden 1993]. Omitted in the 8-session IAPT form [source: White & Hepple 2020].
• Steps: (1) Draft between sessions 3 and 4 and discuss in supervision [synthesis on supervision timing]. (2) Write a prose narrative of the client's story, linking past experiences to present problems, framing procedures as understandable survival strategies [source: Blunden 1993; Parry et al. 2021]. (3) End with the list of TPs and their TPPs [source: Blunden 1993]. (4) Anticipate how the patterns might show up in therapy with you, including around the ending [synthesis; consistent with Ryle 2003 on the map predicting the therapy relationship]. (5) Read it aloud in session and invite corrections [reading aloud: uncertain, widely taught]. (6) Revise it in session 5 until it is mutually agreed; give the client a copy [source: Blunden 1993; Parry et al. 2021].
• Example language (illustrative): "This is my attempt to put into words what we've understood so far. It's a draft: tell me what's wrong or missing."
• Watch for: strong emotion on hearing the letter (common; allow time); agreement too quick to be real; a letter written in jargon or blaming others. Patient involvement and felt accuracy of formulation tools were linked with outcome [source: Ryle 2003 citing Bristow 1997].

4.9 The sequential diagrammatic reformulation (SDR, "the map")

• Purpose / when: First version around session 6 in 16-session CAT [source: Blunden 1993]; built across sessions 4–7 in the 8-session form [source: White & Hepple 2020]. A flow diagram the client and therapist use to locate events, moods and enactments [source: Ryle 2003].
• Steps: (1) Put the core reciprocal role pair(s) at the centre, written generally (without naming specific people) [source: Ryle 2003]. (2) Draw procedural loops outward from the core: each loop shows a TPP as a sequence of feeling, belief, action and consequence that returns to and reinforces the core [source: Ryle 2003; Blunden 1993]. (3) Ryle advises centring the map on role procedures rather than on a "core pain" state, so that harming as well as harmed roles stay visible; White & Hepple add core pain to the map [source: Ryle 2003; White & Hepple 2020 — a difference of emphasis]. (4) Map in session with the client, improvised or from a draft prepared in supervision and offered tentatively; the client may choose colours for different states [source: White & Hepple 2020]. (5) Keep it simple enough to use; check with the client that it is not too complex [source: Ryle 2003; Hubbuck 2008]. (6) Leave space for exits (4.14).
• Example language (illustrative): "Let's draw the pattern. In the middle are the two positions you seem to get caught between. Can you show me where last Tuesday's argument starts?"
• Watch for: the client correcting or adding to the map (good sign of ownership); a map so complex it is not used. The map can also predict which responses the client may pull from you [source: Ryle 2003].

4.10 Multiple self-states work (borderline or dissociative presentations)

• Purpose / when: For clients who switch abruptly between discontinuous states. Based on the multiple self-states model (Ryle; Pollock et al. 2001) [source: Parry et al. 2021; Hubbuck 2008].
• Steps: (1) Identify named states (Hubbuck's examples include Victim, Rage, Revengeful, Bully, Dismissive Contempt, Self-Critic) from the Psychotherapy File, session material and, optionally, the States Description Procedure, a questionnaire on which clients mark which named states apply and how often [source: Hubbuck 2008; administration details in Ryle 2007 — uncertain]. (2) Decide together which states go on the map and where [source: Hubbuck 2008]. (3) Draw a self-states sequential diagram (SSSD): separate cores for discontinuous states (often the "broken egg" layout), procedural loops optional, showing shifts between role procedures [source: Ryle 2003]. (4) Mark flashpoints where unmanageable feelings trigger switches or dissociation; supervision helps locate them [source: Ryle 2003]. (5) Teach the client to ask themselves which named state they are in and what set it off [source: Hubbuck 2008, paraphrased].
• Example language (illustrative): "Just now something shifted: you went from upset to very cold. Which state on the map is that, and what happened just before?"
• Watch for: switches in session; overwhelm or dissociation at flashpoints (see Section 5).

4.11 Recognition: building the observing self

• Purpose / when: From the reformulation onward, focus of the middle phase. The client learns to notice procedures as they happen [source: Blunden 1993; Sandhu et al. 2017].
• Steps: (1) Bring the map to every session and ask the client to locate recent events on it [source: Ryle 2003 (locating events); routine use each session is synthesis]. (2) Make tentative links between past and present patterns and between outside events and in-session enactments [source: Sandhu et al. 2017]. (3) Introduce the "observing eye" as a stance above the pattern [source: White & Hepple 2020]. (4) Set diary or rating-sheet homework recording when target problems and procedures occurred and in what context [source: Wikipedia; Marks 2003]. (5) Gradually hand over: ask the client to do the locating before you do [synthesis, ZPD principle from Parry et al. 2021].
• Rating (detail uncertain): Sources say clients rate their target problems and keep diaries [source: Marks 2003; Wikipedia]. A common format rates, per TPP, how well the client recognised the pattern and how far they revised it, reviewed weekly [uncertain: format].
• Example language (illustrative): "Where on the map were you when you cancelled the meeting? When did you notice? Before, during or afterwards?"
• Watch for: recognition moving earlier in the sequence (afterwards, then during, then before); self-initiated out-of-session recognition is the sign it is working [source: Sandhu et al. 2017 on client-facilitated recognition; time-sequence marker is synthesis].

4.12 Naming and working with enactments in the therapy relationship

• Purpose / when: Whenever a reciprocal role is re-enacted between client and therapist; transference is treated as information and a learning opportunity [source: Blunden 1993; White & Hepple 2020; Parry et al. 2021].
• Steps: (1) Notice the enactment (your pull, the client's shift). White & Hepple's examples: a striving client becoming critical of a therapist they see as critical; a neglected client trying to leave before the therapist can end the work [source: White & Hepple 2020]. (2) Name it tentatively, without blame. (3) Locate it on the map together. (4) Reflect jointly on "what happened between us" [source: White & Hepple 2020, short quote]. (5) Ask what a different response (an exit) could look like, here and now [synthesis].
• Example language (illustrative): "I think something from the map may be happening between us. When I mentioned the homework, you went quiet, and I found myself backing off. Could that be the 'criticised – give up' loop?"
• Watch for: the client experiencing the naming itself as criticism (another enactment); slow down and own your part [synthesis].

4.13 Repairing threats and ruptures to the alliance

• Purpose / when: When the alliance is threatened (withdrawal, anger, missed sessions, sudden compliance).
• Steps [source: Parry et al. 2021, paraphrased]: (1) Refocus on the alliance. (2) Explore the client's experience of what happened. (3) Propose a link to the reformulation. (4) Negotiate a shared understanding. (5) Keep the focus there until resolved. White & Hepple add: address strong re-enactments promptly to prevent rupture and seek repair [source: White & Hepple 2020].
• Example language (illustrative): "You seemed hurt when I had to cancel. I'd like to understand what that was like, even if it's hard to say. I wonder whether it touched the old feeling of being dropped."
• Watch for: repair that is itself a new experience of the role pair (e.g. criticism met with interest rather than retaliation); a resolved rupture can become an exit on the map [synthesis].

4.14 Revision: developing and practising exits

• Purpose / when: Second half (late sessions in brief forms). Exits are new ways of relating to self and others that break a procedure [source: Sandhu et al. 2017; Wikipedia].
• Steps [source: Sandhu et al. 2017 unless marked]: (1) Build the observing self first (4.11). (2) Identify on the map where each loop could be interrupted; write exits on the SDR, ideally in the client's hand. (3) Keep exits personal; they may arise spontaneously or by planning. Common exit types found: self-care, being assertive about one's own needs, self-compassion, motivating oneself. Wikipedia gives the example of expressing anger in a way other than self-injury. (4) Plan each exit in small steps within the ZPD (scaffolding), with a back-up plan for setbacks. (5) Review attempts next session, including feelings and consequences, positive and negative. (6) Explicitly recognise the client's effort. (7) Carry exits into the goodbye letter as a maintenance plan.
• Example language (illustrative): "Where on this loop could you step off? What's one small thing you could try this week when you feel the pull to say yes to everyone, and what will you do if it goes badly?"
• Watch for: generic or therapist-imposed exits (rarely used); exits that are the opposite pole of a dilemma (just swapping roles) rather than a genuinely new option [synthesis drawing on Blunden 1993's definition of dilemmas].

4.15 Change techniques from other models, within the reformulation

• Purpose / when: Revision phase, when an exit needs a specific skill. The framework names behavioural activation, compassion-focused work, behavioural exposure and cognitive methods, always grounded in the reformulation [source: Parry et al. 2021].
• Steps: (1) Locate the target loop on the map. (2) Explain how the technique is an exit from that loop. (3) Deliver the technique to its own standard (e.g. exposure with consent, rationale and graded steps) and within your competence [synthesis]. (4) Review it against the map, not only symptom change.
• Example language (illustrative): "Avoiding the shop keeps the 'unsafe world, hide away' loop going. Shall we plan some small, agreed steps back in, as one way off that loop?"
• Watch for: the technique being taken up within an old role (e.g. compliant or perfectionist doing of homework); name that on the map [synthesis].

4.16 Homework, diaries and outcome measures

• Purpose / when: Throughout. Homework is usually set between sessions; measures guide therapy and can help spot re-enactments [source: Blunden 1993; Parry et al. 2021; White & Hepple 2020].
• Steps: (1) Phase-appropriate tasks: File and history (reformulation), diaries/ratings (recognition), exit practice (revision), goodbye letter (ending) [synthesis on sequence]. (2) Use standard outcome measures at intake, regularly and at follow-up per service [source: White & Hepple 2020; Parry et al. 2021]. (3) Review homework at the start of each session.
• Watch for: non-completion as a procedure (see Section 5).

4.17 Working with the ending throughout

• Purpose / when: From session 1; intensifying in the last quarter.
• Steps: (1) Name the remaining number of sessions in every session [source: White & Hepple 2020]. (2) Explore which procedures the client may use to avoid the feelings the ending evokes (e.g. leaving early, devaluing, becoming unwell) [source: White & Hepple 2020; examples partly synthesis]. (3) Place the ending on the map: which role pair does it activate? [synthesis]. (4) Where loss or abandonment is central, exchange goodbye letters before the penultimate session so there is time to work with them [source: Parry et al. 2021].
• Example language (illustrative): "We have four sessions left. Endings have often meant being dropped for you; I wonder what this one is stirring up."
• Watch for: missed sessions or a crisis near the end; treat as enactment first, risk second, and assess risk properly [synthesis].

4.18 Goodbye letters

• Purpose / when: Last session in standard CAT (penultimate or last per Marks' review of Ryle & Kerr; earlier where loss is central) [source: Blunden 1993; Marks 2003; Parry et al. 2021].
• Steps: (1) Invite the client in advance to write their own goodbye letter [source: White & Hepple 2020]. (2) Write yours: summarise the therapy and the changes, anticipate likely self-sabotage, set out relapse prevention and the exits to keep using, and name remaining work [source: Parry et al. 2021; Blunden 1993]. In brief forms without a reformulation letter, include a brief narrative linking early patterns, TPs and procedures [source: White & Hepple 2020]. (3) Exchange letters, therapist usually first [source: White & Hepple 2020]. (4) Note where the letters agree and differ, and give each person a copy [source: Parry et al. 2021]. (5) If the client has not written one, invite them to write something in the session [source: White & Hepple 2020].
• Example language (illustrative): "I'd like to read you my goodbye letter, and then hear yours. They don't have to agree. The differences are worth talking about."
• Watch for: a client letter that is only grateful (possible placating role) or only dismissive; both are material for the last session [synthesis].

4.19 Follow-up session(s)

• Purpose / when: After the ending, to review maintenance and outcome: one at about three months (or at one and three months); three or more in 24-session work; usually none in 8-session IAPT [source: Blunden 1993; Wikipedia; White & Hepple 2020].
• Steps: (1) Repeat outcome measures. (2) Review the map and letters: which exits are holding, which loops have returned. (3) Decide on further help if needed [steps 1–3 synthesis].
• Watch for: relapse into a core loop; refer on or offer a further contract per service policy [synthesis].

4.20 Contextual reformulation and work with other systems

• Purpose / when: When teams or services around the client are drawn into the client's role patterns (e.g. inpatient eating-disorder care, personality disorder services) [source: Ryle 2003; Parry et al. 2021].
• Steps: (1) Map the client's role procedures together with staff responses (symptoms, acts and staff reactions) [source: Ryle 2003]. (2) Use the map in care planning and staff supervision [source: Ryle 2003]. (3) Help staff spot when they are enacting a reciprocal role and agree consistent, non-collusive responses [synthesis].
• Watch for: splitting between staff, each holding one pole of a role pair [synthesis].

4.21 Brief and extended adaptations

• 8-session IAPT form: no reformulation letter; reciprocal-role diagram introduced at session 4; map, recognition and early exits in sessions 5–7; goodbye letters at session 8 [source: White & Hepple 2020].
• 24-session form: for complex clients, with three or more follow-ups [source: White & Hepple 2020]; self-states mapping (4.10) and contextual work (4.20) are usually needed [synthesis].
• Group and other formats: CAT groups exist (e.g. Hepple's dialogic group approach cited in Parry et al. 2021) [uncertain].

5. Handling problems

CAT's general rule is to read difficulties first as possible enactments of the client's reciprocal roles, locate them on the map, and only then problem-solve [source: White & Hepple 2020; Parry et al. 2021]. Items without a source tag are [synthesis].

• Stuck client (no movement in recognition or revision). Check the ZPD: the task may be too large (shame, withdrawal) or too small (therapist doing the work, dependence) [source: Parry et al. 2021]. Re-check the map with the client: is it accurate, felt as theirs, simple enough? Accuracy and client involvement in the map were linked to outcome [source: Ryle 2003 citing Bristow 1997; Hubbuck 2008 on complexity]. Then shrink the next step and ask the client to locate one event per week on the map. [synthesis on the specific steps]
• Resistance or "yes, but". Treat it as a procedure: often a dilemma (comply or rebel) or a snag (doing well feels unsafe or undeserved) [concepts: Blunden 1993; application synthesis]. Name it on the map and ask which pole you are being cast in.
• Non-adherence (File not done, diaries missed). The framework flags avoidance of the Psychotherapy File as a point to shift from task to relational process [source: Parry et al. 2021]. Ask what doing the homework would mean in role terms (being judged, being controlled); offer a smaller or in-session version; do not simply repeat the instruction, which can enact a demanding–resisting pair. [synthesis on responses]
• Ruptures. Follow the framework's repair sequence (4.13): refocus on the alliance, explore the client's experience, link to the reformulation, negotiate shared understanding, stay with it until resolved [source: Parry et al. 2021]. Own your part in the enactment. [synthesis on owning]
• Therapist pulled into a role (rescuing, criticising, colluding, withdrawing). Use your feelings as data, check against the map and take it to supervision [source: Parry et al. 2021; Sandhu et al. 2017]. Ryle warns that centring the map on core pain can lead the therapist to identify with the victim role and miss harming roles, including the client's own [source: Ryle 2003].
• Overwhelm during history, letter or map work. Slow disclosure to the client's pace [source: White & Hepple 2020]; pause, ground, return to the present and the alliance; break the letter reading into parts; agree how the client will look after themselves after the session. [synthesis on grounding and aftercare]
• State switches and dissociation in session (borderline or dissociative presentations). Map flashpoints where unmanageable feelings trigger switches [source: Ryle 2003]. In session: name the shift gently, help the client identify the named state and its trigger on the self-states diagram [source: Hubbuck 2008 on the self-question], orient to the present, and defer formulation until the client is back within tolerance. Hubbuck notes the sources give little in-session guidance on managing dissociation [source: Hubbuck 2008]; the grounding steps here are [synthesis]. Consider a 24-session contract and specialist supervision.
• Risk escalation (self-harm, suicidality, violence). Standard risk assessment and safety planning take precedence over the CAT agenda; put the self-harm loop on the map once safe, and make exits that replace self-harm a priority (Wikipedia's example: expressing anger other than by self-injury). Active risk of violence and acute psychosis weigh against starting individual CAT [source: Parry et al. 2021]. [synthesis on sequencing]
• Ending reactions (leaving early, crisis near the end, devaluing the work). Name the ending every session and explore the procedures it activates [source: White & Hepple 2020]. A neglected client leaving before the therapist can end is a typical enactment [source: White & Hepple 2020]. With central abandonment themes, exchange goodbye letters earlier [source: Parry et al. 2021]. Hold the contracted end date unless risk requires a managed change [synthesis].
• Client does not write a goodbye letter. Invite them to write something in the final session [source: White & Hepple 2020]; treat refusal as material (e.g. a snag around endings) rather than failure [synthesis].
• Client rejects or is hurt by the reformulation letter. Treat the letter as a draft; revise it together in session 5 until mutually agreed [source: Blunden 1993]. Ask which words felt wrong or blaming, and rewrite in the client's language [synthesis].
• Map too complex or unused. Simplify to the core role pair and one or two loops; check with the client [source: Ryle 2003; Hubbuck 2008].
• Over-compliance (agrees with everything, perfect homework, no change). May be a placating or striving role; name it and ask for disagreement explicitly [synthesis].
• Teams enacting the client's roles (splitting, punitive or rescuing staff responses). Offer a contextual reformulation with staff [source: Ryle 2003].
• When CAT is not the right treatment. If acute psychosis, active continuous substance misuse, serious acute physical illness or active violence risk emerge, pause and refer or stabilise first [source: Parry et al. 2021 (suitability factors); responses synthesis].

Sources

Sources:

• Eight Session CAT IAPT service: description of a model and method (White & Hepple, Reformulation, 2020)
• A Brief Introductory Handout About CAT (Blunden, Reformulation, 1993)
• Parry, Bennett, Roth & Kellett (2021) Developing a competence framework for cognitive analytic therapy, Psychology and Psychotherapy 94(S1):151–170 (White Rose repository PDF)
• Competence Framework for CAT, UCL CORE page (the full framework PDF linked there is not drawn on [uncertain])
• Sandhu, Kellett & Hardy (2017) Exits in CAT for depression, Clinical Psychology & Psychotherapy 24(6) (White Rose PDF)
• History and Use of the SDR (Ryle, Reformulation, 2003)
• The States Description Procedure: clinical implications for the CAT SSSD (Hubbuck, Reformulation, 2008)
• Marks (2003) review of Ryle & Kerr, Introducing Cognitive Analytic Therapy (Cambridge Core)
• Introducing Cognitive Analytic Therapy, Wiley e-book listing (table of contents only)
• Cognitive analytic therapy (Wikipedia) (secondary; used for history, rating/diaries and follow-up timing)

Further reading (not drawn on; referenced via the above):

• Ryle, A. (1990). Cognitive-Analytic Therapy: Active Participation in Change. Wiley.
• Ryle, A., & Kerr, I. B. (2002). Introducing Cognitive Analytic Therapy: Principles and Practice. Wiley (2nd edition 2020).
• Ryle, A. (2007). Report on the States Description Procedure in borderline personality disorder (cited by Hubbuck 2008) [uncertain].
• Pollock, P. H., et al. (2001). Multiple self-states model (cited in Parry et al. 2021) [uncertain].

Not drawn on: ACAT "What CAT sessions are like" page; ACAT "All About CAT" letters article; UCL full CAT competences PDF. The Psychotherapy File and rating-sheet formats are ACAT training materials and were not reproduced.