PurposeIt 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.MethodsA 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.ResultsCAT 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.ConclusionsCAT 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.

ObjectivesService 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.MethodSemi‐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).ResultsThe 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).ConclusionsWhilst 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.Practitioner points 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.