Cognitive Analytic Therapy (CAT) for Personality Disorder

Cognitive Analytic Therapy is a time-limited structured intervention delivered between 8 and 24 sessions.  CAT with patients diagnosed with borderline personality disorder is typically delivered over 16-24 session with sessions lasting 1 hour. The procedure for CAT therapy is clearly defined (1) with a robust set of core components which are well operationalised.  However, CAT is not a manualised therapy since the therapy is guided by formulation. CAT can also be adapted to inform longer term clinical interventions. A bibliometric review (3) provides an overview of papers relating to CAT theory and evaluations.

Core components of CAT:

1. Integration of Theories: Cognitive elements focus on present thoughts, feelings and behaviours. Analytic elements explore how early experiences shape current relational patterns and self-perception.
2. Relational Focus: Emphasizes how people relate to themselves and others. Identifies ‘reciprocal roles’ and recurring patterns.
3. Reformulation: Therapist and client work collaboratively to create a narrative (and/or diagram) showing the client’s problems, origins and patterns. This helps clients make sense of difficulties and see how patterns are maintained.
4. Recognition and Revision: The client learns to recognise these patterns as they occur in daily life. Therapy then focuses on revising or changing these patterns into healthier ways of thinking, feeling and behaving.
5. Time-Limited Structure: Typically lasts 8, 16 or 24 sessions, depending on the client’s needs. Has a clear ending, which is prepared for throughout the therapy, helping clients to better manage endings and separations.
6. Goodbye Letters: Both therapist and client can write “goodbye letters” to reflect on the work done, progress made and possible future challenges.
7. Follow-up: The therapist and client meet to review progress after 3 months.

Fidelity

Practitioners delivering CAT should follow the formal accredited training pathway to become a CAT Practitioner and receive ongoing supervision from a qualified CAT practitioner or accredited supervisor. The accreditation body for CAT in the UK is the Association for Cognitive Analytic Therapy (ACAT).  It maintains standards (training committee, training curriculum, training pathway, competency framework).  It also provides comprehensive resources to support implementation and training and the competency of staff.

Practitioner fidelity can be monitored and evaluated using the ‘Competence in CAT’ tool (CCAT) which has been validated (4) and feeds into an established competency framework.  It is used to measure psychotherapeutic competencies for whole sessions of Cognitive Analytic Therapy and scores competence across 10 domains of therapeutic practice, including CAT-specific competencies and factors common to psychotherapies.

Modifiable Components

CAT takes a largely transdiagnostic approach and it can be used across a wide range of mental health disorders.  This includes anxiety, depressive disorders, personality disorders, eating disorders and complex trauma.  It can be delivered in different populations (e.g. adults, adolescents, learning disability) and settings (e.g. community, forensic environments, inpatient). Barnes (5) provides an account of the use of CAT with young people. A prevention and early intervention model for young people has also been developed (see McCutcheon et al., (6) for an overview). CAT has mainly been used as an individual therapy but can be modified for application to groupwork.  The components of CAT are outlined in the University College London (UCL) competency framework for CAT.

CAT has also been adapted into a consultancy intervention for those complex patients who are seen as unsuitable for psychological therapies (7,8).   This aims to support team interactions and interventions with complex clients.  CAT has also been used to guide overall service delivery (9,10).

CAT is also used to inform and guide reflective practice groups of trainee psychiatrists and other health care professionals within England and Scotland (11).

Implementation Support

The Association of Cognitive Analytic Therapy (ACAT) and CAT Scotland provide individual and organisational support for those wanting to develop the use of CAT according to the process set out in their Constitutions. ACAT has comprehensive resources available to support implementation and training, including resources to build competency of staff (competency framework, curriculum, training pathway, training committee).

Various CAT Practitioner trainings are regularly across the UK and have been run in Scotland when funding has been available to sufficient applicants.  Many introductory and advanced workshops and conferences are also available.

In addition, the Clinical psychology doctorate trainings at the University of Exeter, University of Lancaster, and the University of Liverpool offer a foundation certificate in CAT for their clinical psychology trainees. NHS England (12) has included CAT as an accredited therapy within the IAPT programme roll out, with a significant investment in the training of CAT Practitioners in England and Wales.

CAT Scotland particularly supports training, supervision and CPD within Scotland. Regular training and CPD events are organised by its executive committee. In 2025 are 109 members of CAT Scotland with about two-thirds being CAT Practitioners.

Costs

NES has accredited introductory CAT trainings in Scotland and Scottish Health Boards have given funding to train CAT therapists, although access is limited and many CAT Practitioners have self-funded.

The costs for the most recent Scottish CAT Practitioner training programme (2017-2019) per person were:

£1950 Course fee (per annum for 2 years)

£1000 Supervision fee (per annum for 2 years)

As a CAT trainee the membership of ACAT is £82 per annum, while it is £98 per annum as ACAT accredited Practitioner.

Building Staff Competency

Qualifications Required

Practitioner training in CAT is open to healthcare professionals with a core profession (e.g. psychologists, psychiatrists, occupational therapists, mental health nurses) with existing post graduate mental health or social work qualifications.  However, this is subject to interview and applicants will need access to clients for whom CAT is required.  Applicants for training will normally have completed an introductory training course lasting 2-5 days.

Training Requirements

CAT has a training structure in the UK (supported by ACAT) and internationally (supported by ICATA) which provides structure for a training pathway to Practitioner, Supervisor and Trainer accreditation.

Although there are introductory training courses, becoming a CAT Practitioner requires a 2-year training which has been accredited by the Association of Cognitive Analytic Therapy (ACAT). CAT Practitioner training is offered by a variety of organisations across the UK which are accredited by the ACAT. Three cohorts of CAT Practitioner training have been delivered in Scotland. 

The Practitioner course involves 20 days of academic teaching over 2 years, a requirement for 8 cases with 16 sessions of CAT, weekly supervision, personal CAT therapy and 4 pieces of written coursework. A network of ACAT accredited supervisors provide supervision to support training and wider CAT development in Scotland. ACAT has a regular process of auditing members’ CPD for accreditation quality assurance purposes, both ACAT and CAT Scotland provide support with CPD.

A one-year CAT Foundation Certificated is asl available to clinicians which can be extended and contribute towards a CAT Practitioner training.

Supervision Requirements

It is recommended practice in Scotland that this psychological intervention is conducted under regular supervision with a practitioner who has expertise in a) the intervention b) the clinical area and c) has completed training in supervision of psychological therapies and interventions.

ACAT states that CAT should be delivered by appropriately trained CAT Practitioners or those in training.  Both require ongoing supervision from a qualified CAT Practitioner or ACAT accredited supervisor. There is a minimum of 4 hours of supervision per case which can be delivered in a 1:1 or on a group format

Training to be a CAT Practitioner requires weekly supervision of the first 8 cases over at least 2 years (longer to complete the minimum number of cases). At least 4 hours supervision is required per case (15 minutes supervision weekly). Supervision much be provided by an ACAT accredited supervisor and can be provided individually or in a group.

Following accreditation, ACAT requires practitioners to have a minimum of 1.5 house per month planned supervision in a group or on an individual basis, with a CAT Practitioner or ideally with an ACAT accredited supervisor.

A further 8 supervised cases over a least 2 years following CAT Practitioner accreditation is required to commence the training for ACAT accredited supervisor.

Theory of Change

CAT helps individuals understand and change patterns of behaviour and relationships. It focuses on how past experiences, particularly in early relationships, shape current thoughts, feelings, and actions. CAT aims to help individuals identify and break free from unhelpful patterns, fostering more adaptive ways of relating to themselves and others. Taylor & Hartley (13) review the nature of CAT in relation to outcome research.

Values

Cognitive Analytic Therapy (CAT) is a collaborative, relational, intersubjective approach, which helps people identify and change repeating unhealthy patterns of thinking, feeling, and behaving that developed from past experiences, particularly in childhood relationships.

• Does this relational focus fit with your organisation?

Priorities

CAT can be delivered to young people and adults for the treatment of a range of mental health conditions.  However, it has been found to be particularly useful with complex presentations such as BPD or other personality disorders.

• Would this therapy be beneficial for service delivery in your organisation?

Existing Initiatives

CAT fits with many national policy drivers and initiatives, e.g.  Scottish Mental Health and Wellbeing Strategy 2023 (20), IAPT programme, NICE recommended therapies for patients with ‘Complex emotional needs/’Personality Disorder’ (21), etc.

• Does the approach and focus of CAT fit with your current local priorities?

Workforce

Becoming a CAT Practitioner involves introductory and accredited training pathways and require ongoing supervision with a trained professional.

• Can your service commit to training your staff in CAT and supporting them delivering it in your area?
• Does your service have staff who are available and interested in learning and delivering CAT?

Technology Support

Little technology is required to deliver CAT. The normal requirements for communication and report writing would be expected. 

However, online supervision is possible when required and CAT can be adapted for online individual or groupwork interventions.

• Can your staff access the technology to support training and supervision?

Administrative Support

Administrative support would normally be required to arrange clinical appointments and manage reports/record keeping.

• Is this level of administrative support available in your service?

Financial Support

Health Boards and NES have in the past funded staff to attend CAT trainings, but there can be significant cost attached to funding a staff member to become a CAT Practitioner.  CAT’s transdiagnostic approach also makes it suitable for many applications and potentially increases cost effectiveness.

• Does your service have the financial support to invest in CAT trained staff?

Comparable Population

CAT has been shown to be effective in patients with a wide range of clinical problems.  See Children and Young People, Eating Disorders (above).

• What range of difficulties does your service need to address?

Desired Outcome

CAT contributes to many healthcare policies and initiatives, e.g. Scottish Mental Health and Wellbeing Strategy 2023-2025, IAPT programme, NICE recommended therapies for patients with ‘Complex emotional needs/’Personality Disorder, etc.