The Hexagon: An Exploration Tool
The Hexagon can be used as a planning tool to guide selection and evaluate potential programs and practice for use.
Usability - Rating: 5
5 - Highly Usable
The intervention has operationalised principles and values, core components that are measurable and observable, a fidelity assessment, identified modifiable components
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:
- 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.
- Relational Focus: Emphasizes how people relate to themselves and others. Identifies ‘reciprocal roles’ and recurring patterns.
- 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.
- 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.
- 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.
- Goodbye Letters: Both therapist and client can write “goodbye letters” to reflect on the work done, progress made and possible future challenges.
- 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).
Supports - Rating: 4
4 - Supported
Some resources are available to support implementation, including at least limited resources to support staff competency and organisational changes as a standard part of the intervention
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.
Evidence - Rating: 4 - 5
4 - Evidence
The intervention has demonstrated effectiveness with one rigorous, external research study with the focus population and a control group.
5 - High Evidence
The intervention has demonstrated evidence of effectiveness based on at least two rigorous, external research studies with the focus population and control groups, and has demonstrated sustained effects at least one year post treatment.
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.
Young people 14+ - Rating: 4
Evidence supporting the use of CAT with BPD, includes two randomised control trials (RCTs) and one quasi-experimental design with adolescents. These trials involved delivery of CAT in the context of a specialised early intervention service for BPD.
The first RCT (14) compared individualised CAT (N = 41) with manualized standardised ‘Good Clinical Care’ (GCC; N = 37) in a specialist early intervention service for adolescents displaying BPD (HYPE). Outcomes were collected at baseline, 6, 12, and 24-month follow-up.
The second study had a quasi-experimental design (15) and compared the outcomes for the individualised CAT and GCC (HYPE) groups from the 2008 RCT with adolescents who received ‘historical treatment as usual’ (H-TAU, N = 32), including a 2 year follow-up.
Chanen (16) compared three forms of early intervention for BPD in a trial involving 139 young people (aged 15-25). A CAT-based early intervention service model (HYPE) was combined with weekly individual CAT therapy in one arm of the trial (HYPE + CAT). Another intervention involved HYPE combined with befriending (HYPE + befriending). The third was a general youth mental health service model with befriending (YMHS + befriending). Outcomes were completed at 12 month end point.
Outcomes
- Both CAT and GCC (HYPE service) were effective in reducing psychopathology and parasuicidal behaviour at end of treatment (14). The paper reported that both interventions incorporated the principles of CAT and this led to a great deal of overlap (14).
- At 2-year follow-up, the CAT + HYPE group showed the most marked improvement in internalising and externalizing difficulties and parasuicidal behaviour and these participants had the fastest rate of improvement in internalizing and externalizing difficulties (15).
- There were similar mean improvements in psychosocial functioning (19.3-23.8%) across the three early intervention treatments (16). However, HYPE+CAT and HYPE+befriending were superior to YMHS for treatment attendance and completion.
Adults - Rating: 5
An overview of the effectiveness of CAT across a range of diagnoses is provided in a meta-analysis (17) that includes 25 studies with pre-post treatment outcomes and 9 clinical trials - an increase of 5 RCTs since the previous systematic review in 2014 (18). The largest group of studies involved mixed diagnoses. Five studies involved people with personality disorder, one of which is a randomised control trial (RCT).
An RCT conducted by Clarke et al (19) compared the effectiveness of 24 sessions of CAT with patients diagnosed with a personality disorder (n=38) and treatment as usual (TAU) (n = 40) over 10 months. Changes in interpersonal functioning, symptomatic distress and diagnostic criteria were reviewed at end of treatment.
Outcomes
- Significant improvements in interpersonal functioning and significant reductions in symptomatic distress as compared with the TAU group post-therapy (19).
- A third of CAT participants no longer met symptomatic criteria for any personality disorder (33%). All of the TAU participants continued to meet criteria for a least one personality disorder post-therapy and there was also evidence of continuing personality deterioration in the TAU group (53%) (19).
- Moderate to large improvements in interpersonal problems and large improvements in depression and functioning across non-controlled trials. The effects were small-moderate compared to comparators in the nine clinical trials (17).
Need
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).
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.
1 - Does Not Meet Need
The intervention has not demonstrated meeting need for the identified population
2 - Minimally Meets Need
The intervention has demonstrated meeting need for the identified population through practice experience; data has not been analysed for specific subpopulations
3 - Somewhat Meets Need
The intervention has demonstrated meeting need for the identified population through less rigorous research design with a comparable population; data has not been analysed for specific subpopulations
4 - Meets Need
The intervention has demonstrated meeting need for the identified population through rigorous research with a comparable population; data has not been analysed for specific subpopulations
5 - Strongly Meets Need
The intervention has demonstrated meeting the need for the identified population through rigorous research with a comparable population; data demonstrates the intervention meets the need of specific subpopulations
Fit
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.
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.
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.
1 - Does Not Fit
The intervention does not fit with the priorities of the implementing site or local community values
2 - Minimal Fit
The intervention fits with some of the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
3 - Somewhat Fit
The intervention fits with the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
4 - Fit
The intervention fits with the priorities of the implementing site and local community values; however, the values of culturally and linguistically specific population have not been assessed for fit
5 - Strong Fit
The intervention fits with the priorities of the implementing site; local community values, including the values of culturally and linguistically specific populations; and other existing initiatives
Capacity
Workforce
Becoming a CAT Practitioner involves introductory and accredited training pathways and require ongoing supervision with a trained professional.
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.
Administrative Support
Administrative support would normally be required to arrange clinical appointments and manage reports/record keeping.
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.
1 - No Capacity
The implementing site adopting this intervention does not have the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
2 - Minimal Capacity
The implementing site adopting this intervention has minimal capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
3 - Some Capacity
The implementing site adopting this intervention has some of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
4 - Adequate Capacity
The implementing site adopting this intervention has most of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
5 - Strong Capacity
Implementing site adopting this intervention has a qualified workforce and all of the financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
