BACKGROUND: Self-harm is a prevalent behaviour that has a major detrimental impact on a person\'s life. Psychological therapies have the potential to help, but evidence of effective interventions remains limited. Access and acceptability of interventions can also be a significant challenge, with individuals either being unable to access help or having to endure long waiting lists. Cognitive analytic therapy (CAT) is a time-limited and relationally-focused psychotherapy that may provide a valuable treatment option for people who self-harm. This protocol outlines the methodology for the first feasibility randomised controlled trial (RCT) of CAT for adults that self-harm. The trial will aim to determine the feasibility, acceptability and safety of undertaking larger-scale evaluations of CAT for self-harm within an RCT context.
METHODS: An RCT design with 1:1 allocation to CAT plus treatment as usual (TAU) or TAU alone. Participants will be adult outpatients with three or more instances of self-harm in the past year (target sample of n = 60). CAT will be 8 one-to-one weekly 60-min sessions plus a follow-up session up to 8 weeks after the last session. Assessments will occur at baseline, 12 weeks and 18 weeks after randomisation. Qualitative interviews with participants will gain insights into the feasibility and acceptability of CAT. Feasibility outcomes will be judged against progression criteria.
CONCLUSIONS: CAT may be an effective and accessible treatment option for people who self-harm, providing a more relationally orientated alternative to more behavioural therapies. The proposed feasibility RCT is an important first step in evaluating CAT as a treatment for self-harm.
BACKGROUND: The trial was pre-registered (21/10/22) on ISR CTN (ISRCTN code: ISRCTN75661422).

OBJECTIVE: To compare idiographic change during two formats of guided self-help (GSH); cognitive-behavioural therapy guided self-help (CBT-GSH) and cognitive analytic therapy guided self-help (CAT-GSH).
METHODS: Qualitative inductive thematic analysis.
METHODS: Semi-structured interviews with N = 17 participants with a reliable change outcome on the GAD-7 after completing GSH for anxiety. Changes were categorised and themes extracted.
RESULTS: No differences between CAT-GSH and CBT-GSH were found regarding types of change reported. The five overarching themes found were personal qualities of success, enlightenment through understanding, specific tools and techniques, changes to relationships and tailoring support. Four themes maximally differentiated between the two different types of GSH; CAT-GSH enabled relational insight and change whilst CBT-GSH enabled better understanding of anxiety, new coping techniques and supportive relationships.
CONCLUSIONS: Both common and model-specific factors contribute to patient change during GSH. Whilst all forms of GSH are grounded in the psychoeducational approach, separate theoretical foundations and associated methods facilitate different types of ideographic change.

BACKGROUND: Non-suicidal self-injury (NSSI) presents an increasingly prevalent problem for young people; however, there remains a scarce evidence base for effective, scalable treatments for adolescents. This study aimed to assess the feasibility and acceptability of a brief, cognitive analytic therapy (CAT)-informed intervention for young people who engage in NSSI (CATCH-Y).
METHODS: A case series design recruited 13 young people who met the inclusion and exclusion criteria to participate in the five-session intervention. Eligible participants were aged 13-17 years (M = 15.15, SD = 1.28) and had engaged in NSSI at least once in the previous 6 months. Feasibility and acceptability were measured via recruitment, retention, qualitative feedback and missing data. The secondary outcome measures of personal recovery and motivation were administered pre- and post-assessment, with measures of depressive symptoms and urges to self-injure.
RESULTS: The intervention was found to be largely feasible and acceptable with high rates of recruitment, retention and pre-/post-assessment data completeness. Measures showed preliminary support for positive change in rates of NSSI, urges to self-harm, low mood and personal recovery, although results were mixed. Completion rates for remote assessments were low.
CONCLUSIONS: The findings of this study support further evaluation of the CATCH-Y intervention on a larger scale. In-person assessments may be preferable to remote to ensure good completion rates.

To estimate treatment refusal and treatment dropout rates for cognitive analytic therapy (CAT) and then benchmark these rates against other psychotherapies.
PROSPERO registration CRD4202017081. Systematic searches found CAT treatment studies reporting treatment refusal and dropout rates. Studies were narratively and quantitatively synthesised in a proportional random-effects meta-analysis and moderator analyses were performed. Secondary analyses compared refusal and dropout rates for CAT versus other psychotherapies via direct comparisons in the original studies and via benchmarking these rates against other acceptability meta-analyses for other psychotherapies.
Thirty-four CAT studies were included in the review. The treatment refusal rate was 15.35% (k = 9, 95% CIs 8.78-23.21). The treatment dropout rate was 18.69% (k = 34, 95% CI\'s 15.02-22.62). CAT generated significantly lower dropout rates relative to treatment comparators in the original studies (OR = 0.67; 95% CI 0.48-0.93). Country and younger age were significant moderators of dropout rates. CAT had a comparable treatment refusal rate and was towards the lower end of the dropout range when benchmarked against other psychotherapies.
CAT as a brief and integrative psychotherapy for individuals presenting with typically complex psychological disorders appears a relatively acceptable intervention to patients.

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BACKGROUND: Patients can struggle to make good use of psychotherapy owing to deficits in awareness, and digital technologies that support awareness are at a premium. Currently, when patients participate in cognitive analytic therapy (CAT), the technology supporting relational awareness work involves completion of paper-based worksheets as between-session tasks.
OBJECTIVE: We aimed to design, with therapists and patients, a prototype digital mobile app. This was to help patients better engage in the \"recognition\" phase of the CAT treatment model by providing an unobtrusive means for practicing relational awareness with dynamic feedback on progress.
METHODS: A national online survey was conducted with CAT therapists (n=50) to determine readiness for adoption of a mobile app in clinical practice and to identify core content, functionality, and potential barriers to adoption. A prototype mobile app based on data and existing paper-based worksheets was built. Initial face-to-face user testing of the prototype system was completed with three therapists and three CAT expatients.
RESULTS: Among the therapists surveyed, 72% (36/50) reported not currently using any digital tools during CAT. However, the potential value of a mobile app to support patient awareness was widely endorsed. Areas of therapist concern were data security, data governance, and equality of access. These concerns were mirrored during subsequent user testing by CAT therapists. Expatients generated additional user specifications on the design, functionality, and usability of the app. Results from both streams were integrated to produce five key changes for the reiteration of the app.
CONCLUSIONS: The user-centered design process has enabled a prototype CAT-App to be developed to enhance the relational awareness work of CAT. This means that patients can now practice relational awareness in a much more unobtrusive manner and with ongoing dynamic feedback of progress. Testing the acceptability and feasibility of this technological innovation in clinical practice is the next stage in the research process, which has since been conducted and has been submitted. The important challenges of data protection and governance must be navigated in order to ensure implementation and adoption if the CAT-App is found to be acceptable and clinically effective.

Service users with complex mental health difficulties are more difficult to engage in treatment and drop-out rates are higher, resulting in poorer clinical outcomes. Cognitive analytic therapy (CAT) is widely applied to service users with complex needs and shows promise in terms of engagement and outcomes. The aim of the present study was to examine the \'lived experience\' of service users who have been retained in a full course of CAT treatment to provide important insights to why CAT seems to be an engaging psychotherapy, to inform future CAT delivery and practice with clients with complex needs.
Semi-structured interviews were undertaken with six service users aged between 25 and 47 years who had accessed secondary mental health care services and had received an average of 24 sessions of CAT. Transcripts were analysed using interpretative phenomenological analysis (IPA).
The analysis yielded three superordinate themes with subthemes within these. The first superordinate theme referred to changes due to CAT (e.g., insight, tools to cope). The second theme referred to strong emotions evoked by CAT (e.g., feeling frustrated, scared, and upset). The final theme concerned the process of CAT (e.g., endings and therapeutic relationship).
Whilst service users appeared to develop increased insight and acquire skills, there was variance in experiences of sustained and meaningful change post-therapy. The findings suggest adaptations may be required with these service users such as delivering the sequential diagrammatic reformulation (SDR) in a hopeful way and addressing systemic barriers to \'exits\' being made.
Overall, service users with complex mental health difficulties describe benefitting from CAT, identifying improved insight and the acquisition of tools to cope. However, therapists need to be attuned to the potential fragility of service users and risk of negative affect, particularly during the reformulation phase. Consideration of delivering the SDR in a hopeful way may be therapeutic. Systemic factors such as service users being pulled to maintain the status quo in their relationships, and lack of support for or resistance to change by important others limit service users from availing of \'exits\' from problem procedures. This implicates the need for more attention to systemic and possibly multi-agency working with this group of service users.

Managing the alliance is considered to be a core competency and central therapeutic change process during cognitive analytic therapy (CAT). This study examined latent trajectories of change in the alliance and their relationship to depression treatment outcomes.
Secondary analysis of a randomized controlled trial.
A sample of N = 79 depressed participants completed standardized alliance (WAI-SF) and depression symptom measures (PHQ-9) every session during an 8-session CAT intervention. Growth mixture modelling was applied to model alliance trajectories and to classify cases into different latent classes. Associations between alliance class and post-treatment PHQ-9 scores were examined using hierarchical linear regression, controlling for confounders.
There were two classes of alliance trajectories. The majority class (91%) displayed stable alliance trajectories, whilst a minority class (9%) had initially poor alliance ratings that significantly improved during treatment. Baseline severity and early change in depression symptoms significantly predicted treatment outcomes, but early alliance and longitudinal alliance change did not.
Alliance trajectories did not significantly predict depression treatment outcomes after controlling for initial symptom severity and early change. An important limitation concerns the small sample size, so future replication in larger samples is necessary.

There has been a lack of technological innovation regarding improving the delivery of integrative psychotherapies. This project sought to evaluate an app designed to replace previous paper-based methods supporting relational awareness and change during cognitive analytic therapy (CAT).
We aimed to assess patients\' and therapists\' experience of using the technology (ie, the \"CAT-App\") and to evaluate the relationship between app usage and clinical outcome.
The design was a mixed methods case series. Patients completed the Clinical Outcomes in Routine Evaluation-Outcome Measure pre- and post-CAT. Mood data plus the frequency and effectiveness of relational awareness and change were collected via the app. Therapists and patients were interviewed about their experiences using the app.
Ten patients (treated by 3 therapists) were enrolled; seven completed treatment and 4 had a reliable improvement in their mental health. App usage and mood change did not differ according to clinical outcome, but there was a statistically significant difference in app usage between completers and dropouts. The qualitative themes described by the therapists were (1) the challenge of incorporating the technology into their clinical practice and (2) the barriers and benefits of the technology. Clients\' themes were (1) data protection, (2) motivation and engagement, and (3) restrictions versus flexibility.
The CAT-App is capable of supporting relational awareness and change and is an upgrade on older, paper-based formats. Further clinical evaluation is required.

Despite the central role of formulation in psychological therapy, there is limited research on how formulations are constructed in clinical practice. In Cognitive Analytic Therapy (CAT), a formulation diagram (or CAT map) is used in transforming the client\'s narrative into a psychological understanding of the difficulties. The objective was to build a theoretical model of the processes involved in the early stages of CAT mapping.
A qualitative research design using constructivist Grounded Theory Methodology (GTM) incorporating Interpersonal Process Recall (IPR) methods.
CAT therapists participated in a role-play therapy session with an actor (the \'client\') and made an initial attempt at formulation by mapping. A video recording then formed the basis for a semi-structured therapist interview. Following data analysis, a conceptual model and visual metaphor of the early process of CAT mapping was generated.
The Torchlight model conceptualizes the mapping process as a coming together of unique factors brought by client and therapist, alongside the conceptual apparatus of CAT. Each factor brings a unique light to the unfolding process of mapping and intermixes through a dialogical, collaborative process, analogous to coloured lights mixing to form new colours. The model outlines the mapping process itself as an iterative sequence of tasks, achieved through collaboration, within a growing therapeutic relationship.
The model offers an empirical underpinning to existing accounts of CAT mapping, and a potential tool for training.
The process by which individual CAT reformulation diagrams are started appears to be as unique to the therapist-client dyad as the contents of the map, on the basis of the findings. Mapping faithfully enacts the dialogical and developmental theoretical principles underpinning the CAT approach. The Torchlight model is the first empirically based model of the processes taking place in the creation of CAT reformulation diagrams, in the early stages.