Cognitive Analytic Therapy (CAT) is a collaborative and relational form of psychotherapy. CAT therapists working in neurorehabilitation settings are increasingly using this approach. People accessing neurological services often experience profound emotional and cognitive challenges, including loss, adjustment difficulties and changes in their sense of self (identity). CAT offers a compassionate way of exploring these experiences, focusing on how individuals relate to themselves, their condition and others – including family, friends and professionals they work with.
At its heart, CAT seeks to understand relationships as a broader context for symptoms associated with anxiety and depression. It supports people by helping them to make sense of patterns that may arise following neurological changes, such as brain injury or illness. These patterns of coping and relating can affect how someone feels about themselves, and how they navigate everyday life. Sometimes these patterns are based in early experience, or ‘pre’ injury, or they may arise following a specific event (injury/ illness/diagnosis) because of cognitive changes.
Therefore, CAT seeks to work alongside the person, to understand their struggles, through mapping and writing (known as reformulation). The phase of reformulation often culminates in the sharing of a letter and map, which subsequently leads to phases of ‘recognition and revision’. This marks a change in focus, where the emphasis is on recognising and exploring other ways of responding to those unhelpful patterns – developing ‘exits’, which are more sustainable ways of responding. This way, people can learn and grow, becoming their own therapist with the support of co-created tools and strategies developing during therapy.
CAT is built around shared exploration and understanding. This collaborative approach is a joint venture, where the clinical skills and knowledge of the therapist couple with the personal knowledge and experience of the patient. Together, CAT focuses on creating a visual representation of those patterns and dynamics described. These provide opportunities to develop insight, understanding and emotional processing. Such tools are adaptable, to meet the cognitive profiles of individuals thus increasing access and engagement. As a time-limited therapy, CAT honours space and time to work through endings and transitions. Here the therapist offers the person an ending letter which acts as a further resource, often summarising the personal journey and learning that has taken place through the therapeutic relationship.
The process is often meaningful, increasing personal agency and hope during a time when life can feel unpredictable and overwhelming. Therefore the map guides future uncertainties and possibility, in a manner that is often containing.
Several components of neurorehabilitation are consistent with the CAT model including:
Many therapists using CAT with people who experience cognitive difficulties can tailor sessions to meet these needs. This may include but are not limited to; recorded sessions, summary notes, providing accessible maps, letters and agreeing specific goals.
CAT can also support a more integrative way of working, where the wider social system including families, teams and services experience stuckness despite clinical expertise. It recognises that recovery does not happen in isolation and relationships between families, professionals and services can become strained when working regularly with high levels of distress and behaviours that challenge. CAT helps teams to reflect on the quality of interaction and draws upon the key theoretical principles of reformulation to foster space to understand and navigate any challenges. By drawing upon CAT tools and principles, the wider system can find shared meaning in the struggle and explore new ways to bring cohesion, recognising the importance of integrative collaborative working across the system
Addy, Karen, 'Clinical neuropsychology: The use of the multiple self states model to understand behaviour following traumatic brain injury', in Laura Brummer, Marisol Cavieres, and Ranil Tan (eds), Oxford Handbook of Cognitive Analytic Therapy, Oxford Library of Psychology (2024; online edn, Oxford Academic, 21 Mar. 2024), https://doi.org/10.1093/oxfordhb/9780198866572.013.32, accessed 6 July 2025.
Blundell Jones, J., Walsh, S. & Isaac, C. The Relational Impact of Multiple Sclerosis: An Integrative Review of the Literature Using a Cognitive Analytic Framework. J Clin Psychol Med Settings 24, 316–340 (2017). https://doi.org/10.1007/s10880-017-9506-y
Burke, R. Making Sense of Symptoms. Healthcare, Counselling and Psychotherapy Journal, 2023; vol 23 (1): 8-13 https://www.bacp.co.uk/bacp-journals/healthcare-counselling-and-psychotherapy-journal/2023/january/making-sense-of-symptoms/
Yeates, G., Hamill, M., Sutton, L., Psaila, K., Gracey, F., Mohamed, S., & O’Del, J. (2008) Dysexecutive Problems and Interpersonal Relating Following Frontal Brain Injury: Reformulation and Compensation in Cognitive Analytic Therapy (CAT). Neuro-Psychoanalysis, 10 (1) https://doi.org/10.1080/15294145.2008.10773571
Neuroclinic Podcast July 31st 2021 - Host Ingham Wright speaks to Pip Calvert and Jak Smith on Cognitive Analytic Therapy - Neuro-clinic podcast link: https://www.buzzsprout.com/1652392/episodes/8952367
We extend our thanks to Jak Smith, Ronan Burke, Abigail Methley and Christine Cobley for producing this article.
Photo by Valeria Reverdo on Unsplash
Published on 6th July 2025
