The cognitive analytic therapy (CAT) model

Reflecting relationally through the lens of cognitive analytic therapy (CAT) provides a useful approach to addressing these challenges. CAT, developed by Tony Ryle, is a time-limited relational therapy that helps individuals to understand harmful patterns of thought, emotion and behaviour. CAT identifies common patterns as ‘traps’ (self-perpetuating vicious cycles), ‘dilemmas’ (situations where all choices seem equally unappealing) and ‘exits’ (pathways for meaningful change) (Association for Cognitive Analytic Therapy 2025). Recognising these patterns can help healthcare systems better support individuals with FND.

Dualistic fragmentation

A significant challenge arises from the dualistic fragmentation within medical practice, which artificially separates mental and physical health. This dualism complicates effective care for FND, whose symptoms span both domains. Observing the healthcare system’s physical and conceptual fragmentation – separate facilities, funding streams, commissioning pathways – highlights this dilemma. A critical exit from dualistic thinking involves genuinely integrating the biological and psychological needs of patients. Such integration, tailored individually, promotes healing and reduces fragmentation (Stone Reference Stone, Hoeritzauer, McWhirter and Carson2024).

Additionally, FND often becomes a ‘clinical hot potato’, with core physical and mental health services reluctant or unprepared to manage the complexity and uncertainty associated with the disorder. This hesitancy frequently results in the inadvertent invalidation of patient experiences and triggers exclusion from services. Such exclusion can prompt either patient withdrawal or repeated attempts to secure validation, leading to labels like ‘frequent attender’, further perpetuating negative biases. The dilemma – whether to seek help repeatedly or avoid engaging altogether – thus intensifies the patient’s distress. An effective exit involves fostering inclusion, validation and comfort with clinical uncertainty, ultimately making FND care everyone’s responsibility rather than delegating solely to specialist liaison psychiatry or psychological medicine services.

Moreover, language profoundly influences the experiences of people with FND. Phrases like ‘there is nothing wrong with you’ or ‘the scan is normal’ can inflict lasting emotional wounds, reinforcing exclusionary dynamics. Thoughtful, collaborative communication – such as openly exploring a patient’s condition or asking for their perspective – constitutes critical exits, facilitating understanding and engagement.

In summary, individuals with FND face considerable obstacles within healthcare systems, exacerbated by rigid structures and insensitive approaches. Addressing these challenges requires healthcare providers to adopt integrated, empathetic and validating stances. Through relational awareness, thoughtful communication and inclusive practices, healthcare systems can effectively bridge gaps, validate patient suffering and foster meaningful therapeutic outcomes.

Viewing through a relational lens

Despite our ambition to provide a holistic unitary framework to help people in negotiating the healthcare system, clinicians are only successful with conditions that have a single causal link, such as infections. We struggle with a condition such as FND, as it has overarching symptoms across the physical and mental health domains. The dualistic approach in medicine separates the mind from the body and causes fragmentation to the point that when we meet someone who has neurological symptoms generated by the nervous system but not captured in the pigeonhole of our archaic medical ‘model’, we get flummoxed. Using a relational lens, we can attempt to understand this ‘dilemma’ by just observing how the NHS healthcare system is structured. There are separate buildings, departments and trusts, and separate funding streams, commissioning pathways and metrics. The system’s hard and soft structures reinforce this dualistic fragmentation.

One of the exits from this dualistic thinking lies in integrating the biological and psychological facets and needs of a person in a meaningful way. Integration will look and feel different to each of us but if we all make a shift towards creating this integrated lens, the momentum it generates will go a long way in minimising the dualistic approach. Integration involves seeing a person as a whole and not falling in the trap of separating their mental state examination from their neurological evaluation. Integration heals fragmentation. True integration heals fragmentation properly.

Clinical hot potato

In my view and experience, FND is a hot potato that no core physical or mental health service is prepared to understand or treat. Relationally speaking, core services appear to have difficulty in managing uncertainty and often reject or dismiss suffering that does not cleanly sit within a preconceived model of health and disease. Our own limitations in understanding how our brain and the wider nervous system operate sets us up to invalidate the genuine symptomatology of these patients. The trap is triggered by the exclusion from services and for some sufferers, this translates into feeling unsupported and feeling blamed by the very system that is meant to support them. For others, the trap sets into motion certain behaviours that are designed to make further attempts at gaining inclusion and validation. The latter category of patients is unfortunately labelled ‘frequent attenders’, which only serves to reinforce a negative view and turns the knob of criticism and blame a notch higher. The dilemma (do not seek help or seek help until heard) only deepens.

As an example, a patient with dissociative seizures collapses in the street and an ambulance is called. At the emergency department, clinicians see that they have already been extensively investigated and no organic cause has been found. An initial reaction might be to say ‘There is nothing wrong with you’, which serves to invalidate the person’s suffering. A more thoughtful response may be to explore what may have triggered this episode. Sometimes there is no single trigger, but a curious and open approach helps to join the dots.

The impression I often get is that the symptoms are not believed. Although there is significant literature on the mechanisms that cause FND, no single aetiological framework is successful in explaining the range of different presentations. So, while we wait for more research into the pathophysiological complexity, we need to have an open mind and practice inclusive care.

The exit here is inclusion and validation. It lies in staying with the uncertainty. FND should be everybody’s business, not just liaison psychiatry and psychological medicine services. As it is a heterogeneous condition that can present in primary care or secondary neurology care or in mental health services, clinicians need to adopt an open and validating approach. Rather than excluding people with FND, services need to hold and contain for long enough to take the ‘heat’ out of the equation; this makes it easy to refer to specialist services. This approach is likely to help engage people in treatment and minimise their experience of negative stereotype and bias. It also upholds an important pillar of medical ethics, non-maleficence.

Words wound deep

Language matters. The two previous problems (dualistic fragmentation and clinical hot potato) seem to infuse a sense of ‘urgency to dismiss’ and there is little time available to focus on the language we employ in FND. From ‘there is nothing wrong with you’ to ‘the scan is normal’, words can cause confusion, distress and everything in between.

Words convey our subconscious thought processes. Body language along with the words we use sends the patient all the signals and we have choice in the matter; choice between an approach that is rapid fire and one that is thoughtful and measured. If the latter is adopted, the right words can come to the surface.

Inappropriate language can set up traps and dilemmas. It tends to stay with the patient for a long time, reducing the chances of engagement and prolonging misery. The exits here are characterised by an active process of finding the right words until the right words become part of the usual lexicon. An empowering phrase such as ‘Let us try and understand what is going on here’ or an inquisitive one, ‘How do you think we should deal with this?’, wrapped up in a warm, sensitive and collaborative framework can foster a deep sense of feeling understood.