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Letters in Cognitive Analytic Therapy: The First Letter

One of the things that usually happens in Cognitive Analytic Therapy (CAT) is an exchange of letters between the person in therapy and the therapist. In a sixteen or twenty-four session CAT, the therapist will usually offer you a letter as one way of feeding back their understanding of your difficulties.  They may also offer you a diagram or map, which uses words, arrows, and sometimes images, to help describe your difficulties in a visual way.

The letter marks the end of the first phase of therapy, when the therapist has listened carefully and tried to explore your difficulties with you. This phase is known as reformulation.  CAT therapists see the letter as a way to move from this first stage of listening, exploring and understanding, into a more active stage of therapy.

The idea of an ongoing conversation or dialogue between the two people in therapy is important in CAT.  A letter is one way to help this conversation develop and deepen.  It can also be useful to refer back to throughout therapy, to help keep sessions on track.  It can also be a useful reminder after therapy has ended.

When am I likely to be given my letter?

You will usually receive a letter between session four and eight. It’s more likely to be shared later if you are having a twenty-four session therapy. If you have a briefer eight session therapy, a letter may not be offered.

What if I have trouble reading or writing?

For some who lack confidence in reading and writing, the idea of a letter might be stressful.  There is never any pressure to use written letters if you struggle with reading and writing.  Your therapist can find other ways to feed back what they have understood about your difficulties and invite your response.

What will be in the letter?

The letter usually follows an accepted structure, but it is always personal and specific to you. Your therapist will read it out loud to you in the session, and will also give you the letter and keep a copy. You can make notes on it as your therapist talks. If at any point you want the therapist to pause, or you need a break, you can say this.

The first letter will usually touch on:

– why you came into therapy – this will usually refer to the main problem patterns you describe in your early sessions

– some of the important events in your life that you’ve talked about with your therapist

– past and present relationships which have influenced you

– past and present influences in your broader world – this might include your culture, where you are living, social trends, world events, politics, and messages you might have picked up through the attitudes of others

– the main issues that stand out to your therapist from what you’ve shared over the first few sessions, and what you’ve understood together

– how the difficulties that brought you into therapy have come about. Your CAT therapist tries to make sense of how and why your problem patterns developed in the first place. Often problem patterns and symptoms develop as ways to survive other challenges in your life. There are often very good reasons why problems started, as a way to protect you from other painful or distressing situations

– your strengths and ways you have survived despite the challenges you’ve faced

– a summary of up to three or four problem patterns, which the therapist will offer as possible areas to work on in therapy

How does the letter relate to the rest of the therapy?

The letter may then raise some ways these patterns might come into play in the therapy relationship. These are not firm predictions but can help to highlight patterns that might feel a challenge if they happen between the two of you, and get in the way of progress. By naming them in the letter, you can both be more alert to these possibilities. If they start to happen, you can hopefully spot them earlier. You can treat them as opportunities to think and talk together about what’s going on, rather than get stuck, withdraw, or end therapy in an unplanned way.

Your letter will usually refer to the ending of therapy to help both you and your therapist this in mind.  It may make some guesses about any particular issues that the ending might bring up for you.

What happens next?

The letter will usually end with an invitation for you to think about what the therapist has written, and to tell them what you think. Time for this is usually protected in the session, but you can also take the letter away with you to think about, and discuss it at the next session.

There may be parts of it you are not sure about, and you can ask your therapist any questions to help get more clear. You might not agree with it, or you might feel that some of the details are not right. It’s fine to say this if so. Or you might feel the emphasis needs to be different.

It’s unlikely the letter will perfectly capture everything, but it will be a way your therapist will try to give a useful ‘snapshot’ in words describing what therapy might involve.

Some CAT therapists invite you to write back to them after receiving the letter. There is no pressure to do this but it can be a chance for you to get your thoughts about it down in writing.

Do I get any more letters later on in the therapy?

Your therapist will also offer you a letter towards the end of therapy, and will invite you to write to them about what the therapy has been like for you. Read more about ending letters here.

Letters in Cognitive Analytic Therapy – The First Letter by ACAT Public Engagement Team
CC BY-SA 4.0