DOI: 10.1111/papt.12305 ISSN:

A systematic review of service user’s experience of cognitive analytic therapy (CAT)

Nadia Balmain, Yvonne Melia, Helen Dent, Karen Smith
  • Psychiatry and Mental health
  • Arts and Humanities (miscellaneous)
  • Clinical Psychology
  • Developmental and Educational Psychology


It is increasingly acknowledged that understanding of the process and impact of psychotherapy is enhanced by awareness of the experience of service users. Cognitive analytic therapy (CAT) was developed as a time‐limited and integrative psychotherapeutic approach. Although reviews have been published on CAT outcome studies, no reviews are currently available on service users’ experience of CAT. This paper aims to systematically review and synthesize what is known about service users’ experience of CAT.


A systematic search of HDAS, Cochrane, and Ethos databases was conducted. Following this, fourteen papers were selected for review, appraised using CASP tools, and then thematically synthesized.


CAT therapy enabled service users to acquire useful knowledge and skills. Most service users found CAT tools helpful in gaining insight into their reciprocal roles and patterns. However, CAT was experienced by some service users as a painful, frightening, and upsetting process, particularly in relation to the sequential diagrammatical reformulation (SDR) and reformulation letter. The importance of the therapeutic relationship was highlighted, as well as difficulties some service users had with trusting their therapist.


CAT is helpful in supporting service users to understand their patterns and to identify useful coping skills. However, some service users can experience strong emotions in therapy and struggle to trust their therapist. Greater attention to working within the service users’ zone of proximal development (ZPD) and engendering hope during the reformulation stage may attenuate some of these risks. Recommendations are made for future research directions.

Practitioner points

CAT therapy enables users to develop insight to their reciprocal roles and patterns and helpful coping skills.

The service user’s ZPD should be worked with when delivering CAT to manage risk of distress and reciprocal role enactments and enhance the working alliance.

CAT therapists should explore ways to engender hope by attending to any helpful reciprocal roles, patterns, and exits.

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