A case study of cognitive analytic therapy with a client diagnosed with psychotic depression

John Cartmell, 2017. A case study of cognitive analytic therapy with a client diagnosed with psychotic depression. Reformulation, Winter, pp.22-27.


Effective treatments for depression are detailed in NICE guidance (NICE, 2010). These interventions attempt to ameliorate client suffering through a variety of means, from challenging thoughts and modifying behaviour, to discussing internal conflicts in relationships and/or repeated patterns of self-other interaction.

CAT has been growing in usage over the past 30 years and is impactful on a wide range of presentations, including for those diagnosed with personality disorder (Ryle, 1997, 2004). CAT is a time-limited therapy, consisting of 16 or 24 sessions; it integrates ideas from cognitive and psychodynamic approaches and has added influences from Bakhtinian and Vygotskian traditions (Bakhtin, 1981; Vygotsky, 1978).

CAT aims to work collaboratively with clients in developing their understanding of themselves; CAT focuses on the relational aspects of a person’s difficulties, the aim of which is for the client to better manage their maladaptive and repetitive patterns of behaviour, termed traps, snags and dilemmas.

CAT employs a structured therapeutic approach and several tools to help clients achieve recognition and revision of problematic patterns of relating to themselves and others. This understanding of the clients’ difficulties is presented following an extended assessment process by the use of a sequential diagrammatic reformulation (SDR) and a reformulation letter. These patterns then become the focus of the remaining therapy sessions. A goodbye letter is shared with the client at the end of therapy and reciprocation is encouraged. It is hoped that the giving and receiving of goodbye letters facilitates the integration of new learning and allows for realistic reflection and perspective taking of the achievements and regrets of therapy. A comprehensive introduction to CAT is provided by Ryle (1990, 1995) and Ryle and Kerr (2002).

As far as the author is aware, there are no outcome studies in the CAT literature regarding the effectiveness of the model with clients diagnosed with psychotic depression. Several studies have shown its impact on working with psychosis and co-occurring difficulties (Graham & Thavasotby, 1995; Kerr, Birkett & Chanen, 2003; Kerr, Crowley & Beard in Johannessen, Martindale &Cullberg, 2006; Gleeson et al, 2012), and depression (Dube, 1996; Bamber, 1997; Hepple & Sutton, 2004; Katsigiannopoulos, Garyfallos, Pazarlis & Adamopoulou, 2008), but none of this specific presentation.

NICE guidance for psychotic depression suggests that CBT should be supplemented with antipsychotic medication (NICE, 2010). However, what of those clients for whom this does not work? Clinical experience suggests that CAT may offer something different; the type of structured collaborative exploration of hard to understand experiences offered in CAT may be of benefit to these clients.

The following is a case study of a client who did not respond to standard NICE recommended treatment provided both in the community and inpatient units. A CAT informed approach was taken with the client. It is intended that this case study will raise discussion regarding the utility of CAT with clients who do not respond to established treatment approaches. The clinical implications and personal reflections are discussed.

Case Description

Background information

Daniel was a man who lived alone but would regularly stay overnight at his parent’s house. Daniel was an only child with several half siblings. He also had cousins that he was close to in his youth. His mother was registered blind shortly after his birth and his father, while present, was described as a ‘follower’.

He left school with no formal qualifications having struggled with English in primary school to the extent that he was held back a year, and subsequently was made to attend an alternative school (he would later be diagnosed with dyslexia). During his secondary school education he felt contained rather than taught, that the teachers concentrated on the students they felt were ‘worth their efforts’.

Daniel entered work at sixteen and described feeling lucky to have a job. He had several roles over the next few years, eventually working for an industrial company. He enjoyed this work as it involved factory level ‘bantering’ relationships with his colleagues. He was successful in the job and was promoted which led to a separation from his work colleagues. Daniel began to experience high levels of anxiety concerning his previous work colleagues’ feelings towards him. He also started to hear voices.

Daniel’s interpersonal relationships seem to have been restricted prior to this work experience, and this exacerbated these patterns. He suggested he had some brief romantic encounters but nothing of any significance to him. He had a small group of friends at work, all of whom seemed to distance themselves from him following his struggles with mental health difficulties. He became depressed, and the voices encouraged him to make attempts on his life.

Daniel has had a long history of input from mental health services, and was seen by the CMHT from 2007 to 2013. He was discharged, and re-referred by his GP in 2014 who suggested Daniel had been following commands by voices to harm himself. Most recently he had been stopped in his attempt to harm himself by his mother; prior to this, however, Daniel had taken overdoses and cut his wrists with the intention of ending his life.

In 2014 Daniel reported that he could not socialise as he felt people were laughing at him, that he was very frightened when he tried to go out, he had difficulty in making decisions. He suggested that when he became frustrated he might head butt walls. CPN intervention focused on social anxiety. He was signposted to several community groups and attended an anxiety management group facilitated by a community support worker.

Unfortunately Daniel continued to experience high levels of social anxiety and fluctuating mood. This led to crisis resolution and home treatment (CRHT) team input when his CPN became concerned that he had made plans to hang himself. Daniel continued to pose a significant danger to his own life, therefore the psychiatrist discussed inpatient admission and potentially Electroconvulsive Therapy (ECT). He was admitted informally for ECT, however, after a period of observation Daniel was discharged without having received any treatment, including ECT. It was at this point that a referral for a psychological assessment was arranged.

Referral to for psychological assessment

Daniel agreed to receive 16 individual CAT sessions, the details of which are provided below. Daniel also agreed to a one month consolidation period and follow up review. Daniel also received input from a peer recovery support worker who encouraged him to engage in activities consistent with his overall care plan, e.g. going to the gym.


Daniel’s target problem procedures (TPPs) are described as part of the reformulation. Daniel’s assessment also included the use of CAT specific tools, including the psychotherapy file.

The psychotherapy file is a collection of common traps, dilemmas and snags that clients are encouraged to consider for relevance to their experience. This helps guide the assessment process, scaffolding the process of assessment to facilitate engagement and retention of new learning.

Daniel described feeling very low and fearful of being alone. He was socially isolated and felt hopeless for change; however he was able to identify the following goals for therapy:

•             to feel less ‘on the outside’ and disconnected from others

•             to improve his self-esteem, to be more ‘at peace’ with himself


A CAT reformulation was developed collaboratively with Daniel then presented in prose before being expanded using the SDR (Appendix 3) and TPP rating sheets. These tools ensured appropriate consideration of Daniel’s zone of proximal development (ZPD), i.e. the limit of his ability to (cognitively and emotionally) process the information presented at that time.

Daniel’s difficulties with dyslexia were also addressed. He suggested that a prose reformulation would be acceptable as he had improved his reading in adulthood.

Daniel acknowledged the importance of dismissal (both other to self and self to self) in creating and maintaining his difficulties, and this was detailed in both the reformulation letter (Appendix 1) and the SDR. Daniel agreed that the developed SDR was an accurate reflection of his dominant procedures, however, he also held beliefs about the cyclical nature of his mood irregularities, and the biological nature of his psychotic experiences. Exploration of what these ideas gave him, i.e. justification of avoidance and ability to ‘side step’ critical responsibility for his difficulties, enabled Daniel to engage with the process. Daniel was able to use the SDR and TPP rating sheets to monitor and reflect on these habitual patterns of interaction.

Daniel bottles up his emotions in reaction to (perceived and actual) dismissal from others. This had developed into a self-sabotaging pattern, resulting in dismissal of his own needs and the invitation of others to do likewise. Over time this pattern had necessitated a second procedure of ‘switching off’ from his life and emotional experiences. His target problem procedures were identified as:

•             ‘On switch’ – Feeling that others cannot help me, I bottle up my feelings. Over time I become overwhelmed and attack myself or others. This increases my sense of worthlessness.

•             ‘Off switch’ – I disconnect from my life when feeling low. This offers me a numbing, pain-free calmness, but also removes consequence and concern and so I can be vulnerable to self-attack.

These short cut descriptors were used to facilitate engagement with the patterns and reflected the therapist’s attempts to adapt therapy to Daniel’s ZPD.


The letter and SDR were important in scaffolding the intervention and our new understanding of Daniel’s experiences. These tools offered containment with active engagement of procedures through discussion of their place on the SDR. This was a stark contrast to his experience in school of containment without consideration.

Target problem procedures were written out in prose on rating sheets and referred back to in all subsequent therapy sessions. Daniel’s targets for intervention were as follows:

Recognition of bottling up/flying under the radar procedure

Recognising this habitual way of avoiding attention and withholding his internal experience from others was important as it connected Daniel’s childhood neglect and forced independence to his current experience of overwhelm. The SDR and TPP rating sheets were important tools in facilitating reformulation of these processes and the central role of avoidance in maintaining his low mood.

Revision of sabotaging attempts to receive care

Daniel struggled to know how to change to reduce the frequency of being dismissed by others, but he was brave in attempting to elicit care from others. This offered practical examples to explore the impact of his ‘core pain’ of worthlessness (using the SDR) on his subsequent performance in the task of obtaining care.

Revision of loss of ‘control’ during dissociated states

Daniel suggested that his mood would drop and he would have no choice but to continue with coping strategies that increased dissociative experiences. While in these states he may be more dangerous to himself or others. Through therapy, Daniel was able to practice grounding techniques which helped to ‘break out’ of the off switch mode.

Importantly Daniel was explicitly told that the intervention was not to remove his current coping strategies, but instead to facilitate increased flexibility in response to low mood.

Through this effort towards recognition and revision of problematic patterns Daniel started to attend to his experience of life, which he had previously assiduously avoided. This may have reflected a change to his core pain of worthlessness; he had started to consider himself worthy of consideration. He also began to acknowledge the impact of his internalised reciprocal roles, and this facilitated a change in perception towards his mood states; he was able to acknowledge the negative consequences of his avoidance and its likelihood in leading to cyclical mood changes.

Daniel also became critical of himself when considering his need for a caring other; he considered that he should just be able to control his need. To investigate this we added an idealised self-state to the SDR. Characteristics such as independent, skilled, acknowledged and robust were desirable, and the consequence of not achieving this state was overwhelming shame. This seemed to lead to a direct switch from coping through bottling up to self-criticism. This led to the formulation of the ‘independence snag’, where Daniel and I came to understand his difficulties in accepting interdependency caused a state switch from coping to critical which could result in serious risk to himself.

This in turn led to a further review of the target problem procedure, defined as:

Creation of an alternative healthy self-state

Daniel, through the improved strategies to gain other’s care also came to see himself as worthwhile. This was mapped on his SDR as a repetition of the ‘reaching out’ and receiving limited comfort procedure with a changed result in his experience of some tolerable disappointment and a recognition of other’s ability to ‘put effort in’ and thereby acknowledge him. We mapped this as a reciprocal role of considerate to acknowledged, and conceptualised this as a healthy state to obtain.


Daniel’s goodbye letter (Appendix 2) emphasized the need for effortful practice of seeking care and acceptance of partial amelioration of his pain. That this could lead to a stable healthy self-state reflecting one aspect of his idealised self – being acknowledged. It was important that the letter strike a balance between an understanding of Daniel’s difficulties, the developed exits and his ZPD. This balance was achieved through supervision.

Daniel reciprocated with a letter of his own. It indicated that therapy had been hard but that he felt we had ‘delved deep into his thought processes’, his ‘erratic nature’ and ‘different interpretations of them’.


Few studies address the application of CAT with presentations like Daniel’s. This case study suggests that in complex presentations, often where first line interventions have been tried, a CAT approach may be beneficial. Moreover, the addition of antipsychotic medication without a psychologically appropriate rationale can lead to service users internalising a biological understanding of their experiences which may compound their dismissing self-to-self reciprocal role. Daniel demonstrated positive changes in several areas, including his ability to reflect, to consider himself worthy of reflection, and his openness to behavioural experimentation. However he did struggle to overcome the conflicting explanations offered. Part of this may be the simplicity of a biological explanation (at face value) versus the complexity of a dissociated part-of-self leading to externalised voices. There are a number of factors to take into account when considering differences between usual treatment and CAT. Usual CMHT treatment starts with input from a CPN. This may be CBT-informed but will not include a robust intervention of the longitudinal factors involved in maintaining any difficulties. Further input from a psychiatrist may similarly focus on the client’s here and now difficulties. As a result the treatment regime may encourage the dampening down of emotional experience as a coping strategy. Either of these responses in Daniel’s case may have repeated the pattern of limited care and eventual dismissal.

Daniel suggested that his CPN input was valuable in offering him a safe relationship in which to speak without fear of dismissal. This will have offered a reparative relationship, potentially facilitating later engagement with CAT, however it did not acknowledge or change the pattern of bottling up his feelings (or his sense of worthlessness when he could not). Previous therapy work had also been unstructured, lacking the scaffolding inherent in a 16 session CAT endeavour, meaning that any therapy model offering more structure could have been as impactful.

The days and times of Daniel’s sessions were stable throughout intervention. This has not always been the case in my practice, nor for the previous CPN or psychiatrist. This greater level of predictability could have been important to Daniel’s engagement and outcome. The importance of Daniel’s early awareness of his mother’s blindness and the potential impact on their attachment relationship was emphasised in the reformulation. After his initial exposure to not being metaphorically ‘seen’ the decision to hold him back was discussed as an example of his incapacity and others’ lack of inclusive decision making. Incapacitation and forced withdrawal from decision making could be important in understanding long term depression and psychotic depression; voices could be understood as externalisations of internalised critical others in order to manage powerlessness and exclusion.

Daniel remained at risk of mood reductions and experienced critical voices. He suggested that therapy had provided opportunity to consider his habits and space to practice alternatives. His TPP rating sheets suggested a small, steady improvement in his ability to recognise and revise both TPPs. This could be a positive first step away from a destructive intra and interpersonal style, but could also represent Daniel’s attempts to comply with the perceived wishes of a valued therapist. Only time will tell which possibility is most correct.


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Bamber, M. (1997). An evaluation of three cognitive models of depression.Clinical Psychology Forum, 99, pp 3-8.

Dube R. (1996). Treating depression through cognitive analytic therapy. Mental Health Nursing, 16, pp 25-27.

Gleeson, J.F.M., Chanen, A., Cotton, S.M., et al. (2012). Treating co-occurring first episode psychosis and borderline personality - a pilot RCT. Early Intervention in Psychiatry, 6, pp 21-29.

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Ryle, A. (2004). In Bolton, G. Howlett, S. Lago, C. and Wright, J.K. Writing Cures: An Introductory Handbook of Writing in Counselling and Psychotherapy. Writing by patients and therapists in Cognitive Analytic Therapy. (pp 59-71). Brunner Routledge

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Appendix 1: Reformulation


Dear Daniel,

Here is the letter I promised to write. It is my attempt to draw together your life experiences, your patterns of coping and how you have come to feel about yourself. As we are coming to a new understanding of your life this letter should be thought of as a draft, and as such open to new knowledge or insights.

Daniel I heard how important your parents are to you, how your mother felt like ‘the voice of reason’ when you felt overwhelmed and how unsafe you feel on your own. Where could this fear for your safety have come from?

We thought about your childhood, how you were initially close to your half siblings and parents but would even then feel on your own with your emotions. We wondered together about the impact of your mother’s eyesight difficulties on this experience; the two-way connection between infant and caregiver in a child’s earliest years is achieved to a large extent through holding of each other’s gaze. The child and caregiver are able to share a sense of each other, to develop a sense of safety in each other and to suggest something of the emotional meaning each holds for the other. Could your mother’s blindness have meant that as the infant you searched for connection and reassurance you were unable to find it?

It might be hard to say, but it seems there are clues that may point in that direction; your difficulties in adulthood with holding eye contact for instance, and your discomfort with physical affection. Even your sense of worthlessness could stem from these early years. However it seems too simplistic to suggest your mother’s eyesight to have been solely responsible.

You also described a difficult school experience, especially with English due to your dyslexia. I was saddened to hear how you were held back and then taken out of mainstream schooling all together. How you were never talked to about these changes, and had no say in what was to happen to you. I wonder how powerless this would have left you feeling, how you might have come to understand these decisions – did you decide that you must not be good enough to progress? That you were somehow ‘defective’?

Later experiences in this alternate school may have worsened this sense of yourself as not good enough; you described how teachers focused their efforts on those they considered ‘worthwhile’. How did this leave the rest of you feeling? Dismissed? Contained in a school environment without any schooling really taking place?

I wonder how this would have registered with you. From your description you joked and laughed with the other children but had nobody to turn to who could be trusted to share your concerns with. I wonder if it seemed (like with your earliest contact with your mother) as though others were unreachable, close but unwilling or unable to respond. Perhaps it was less painful to keep people at bay (through jokes and acting the clown) and dismissing your own feelings and needs?

A sense of having no options, no choice but to comply with others wishes may lead you to feel frustrated and low. Could this explain your experiences of angry critical voices?

Since leaving school you suggested you felt lucky to have a job, how you have never really had any romantic relationships because you consider yourself to have nothing to offer. Changes in your role at work seem to have left you feeling unsettled and isolated, removed from the ‘comfortable bantering’ relationship you had in the saw mill. It was at this time you suggested you started to feel worried about how others felt about you, and what they might be saying about you to each other. Your usual coping strategies of bottling up these feelings left you overwhelmed, highly anxious and low. It is as though the way you have coped has made it harder to feel able or motivated to seek out others, and by doing so increased your sense of being stuck, helpless and worthless.

In our sessions we have noticed your expectations of judgement from me (& others), and your discomfort at revealing your thoughts and feelings. We have seen the sense of helplessness and its blocking of positive action. Through our remaining sessions I believe that your discomfort at talking about yourself can be reduced. That we can come to know you a little better and find new ways of being with yourself and others.

It will be important for you to spend time reading and re-reading the letters, maps and other resources we use as part of this therapy, these ideas are not easy to emotionally sit with and will therefore need time to process. If you are able to do so, over our next 12 sessions we will work on recognising the patterns of withdrawal and passivity that leads to your anger and fear towards yourself and others. By doing so we may be able to help you to see the worth you hold despite the life experiences you have endured.

Yours sincerely


Appendix 2: Ending


Dear Daniel,

As we come to the end of our time in CAT I wanted to offer you some means of considering our achievements and any missed opportunities in the future.

When we first met you were concerned about how I might think about you and were reluctant to risk sharing your experiences. However over time we came to understand your expectations of attack (from both yourself and others) and coping through avoidance as coming from your experiences of being treated as worthless.

You preferred to keep your feelings, thoughts and concerns to yourself which we understood often led to you feeling that others did not care for you, could not help you and strengthened your sense of isolation. When you did reach out, others would dismiss or eventually withdraw from you, again creating this sense of aloneness and need for safety in independence.

We noticed how you went about asking for help might make it more likely that others would dismiss you; you were unlikely to insist on the person’s full attention, could be vague about how you felt and what you wanted. Your usual way of coping when this happened would be further withdrawal and attempts to control your emotional turmoil. Unfortunately, due to feeling worthless you would become critical of yourself as you attempted to control your feelings, so much so that the way in which you addressed yourself started to become painful and was pushed away. It was then that this attacking of yourself started to become experienced as hurtful, annoying and destructive voices. At times these voices and the extreme low mood you sometimes find yourself in have resulted in attempts to kill yourself.

Currently you cope with these voices through withdrawal from others and a ‘switching off’ from yourself and life through computer games and television. I suggested some alternative coping options, to offer flexibility in your response to distress. For example, using ‘look, point, name’ to disrupt the voices in real time, and to use yoga and grounding techniques (like the 54321 exercise) to stay present.

The biggest and hardest change we spoke about was how to change your need for independence and challenging your impression that others were unavailable or unhelpful. On the map we saw time and again that when you reached out others responded with some comfort but eventual dismissal, that this led you to feel alone and reinforced your feeling of worthlessness.

Instead we considered ways to improve your ‘asking for help’ technique, coming to define the technique as having three steps, which were:

1) Location – think about where you are in relation to the person you are speaking to. Are you making it clear that what you are saying is important, and that they should listen? Maybe sit near to the person

2) Prompt the importance – literally saying ‘this is important’, or giving other cues for others to understand how important what you are saying is to you, e.g. make eye contact and use hand gestures

3) Be honest and specific – people are more able to respond the more they know, try to be specific, e.g. ‘I have been on my own all morning, I’m feeling really miserable and I need you to listen to me’. This example clearly states what has happened, how you are feeling and what you need from the other person.

Through using these steps you were able to gain further support, however continued to feel low. We recognised that this change, although important was only the beginning.

Through continued use of this technique, and continuing to seek support we saw that you were able to access a different response – one that recognised the effort people put in to helping you. We saw how when people put effort in, even if you continued to feel bad, you were able to appreciate their effort, to feel heard and acknowledged. This we thought about as a brand new self-state, where you could feel acknowledged in response to considerate others.

It will take huge effort to always feel in this state, and may ultimately be impossible to sustain at all times, but the routes to it are clear. It is my hope that through accessing this position, overtime the likelihood of withdrawal from and attack of yourself and others will reduce, meaning a new relationship with yourself, your voices and others can be formed.

I wonder if there you have any regrets in coming to the end of therapy? Perhaps there are some experiences we did not explore? I know you spoke about how good it had been to have a reliable other to speak to about your experiences, to help understand and make sense of them and I wonder if it will be hard to replace this contact? Within this concern, I am able to hope that the work we have undertaken may allow you to replace this contact, either by encouraging yourself more or being more persistent in getting other’s support of you. Looking back over the exits detailed on the rating sheets, the map and the letters may offer you moments to assess where you are and what you might do differently.

Daniel, I have enjoyed our time in CAT together and I sincerely hope that the process of mapping and coming to understand the sabotaging patterns you fall into has been helpful for you. Please do look over the attached map, think about the exits we have identified and continue to push others to treat you how you wish to be treated.

I look forward to reviewing your progress in a month’s time.

All the very best


Full Reference

John Cartmell, 2017. A case study of cognitive analytic therapy with a client diagnosed with psychotic depression. Reformulation, Winter, pp.22-27.

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