NHS Talking Therapies (TT) is England’s main service for treating people with common mental disorders. Prior research has shown that a high proportion of people receiving TT ‘high intensity’ treatment have concurrent personality difficulties and that these are associated with poorer TT treatment outcomes. We developed a training workshop to enhance the skills, knowledge, and confidence of TT therapists in the treatment of this population and conducted a mixed methods evaluation to investigate whether the training was acceptable to staff and whether it had any impact on client outcomes. A quantitative survey (n=46) and qualitative interviews (n=6) were undertaken with staff and in parallel, we analysed the anonymised health outcomes of two client cohorts, treated pre-training (n=2434) and post-training (n=2358). Multi-level, difference-in-differences analyses revealed statistically significant cohort differences between the last and first scores on the domains of depression (–2.53, 95% CI: –3.02, –2.04), anxiety (–2.70, 95% CI: –3.15, –2.20), social functioning (–2.17, 95% CI: –2.88, –1.47), and phobia (–1.19; 95% CI: –0.29, –0.17). Therapists reported finding the training helpful, particularly in managing therapeutic alliances and enhancing the interpersonal effectiveness of their clients. Furthermore, the survey revealed a positive change in therapist attitudes to, skills related to, and knowledge of personality difficulties post-training. However, staff also suggested that broader structural changes and more resources are needed for TT services to better support clients with personality difficulties. Training initiatives such as this appear to be feasible and helpful for therapists, and may help to optimise client outcomes.

Key learning aims

1. (1) To understand the potential utility of online training for therapists, in their management of clients with concurrent personality difficulties.

2. (2) To understand high intensity therapist perspectives on attending a workshop to support tailoring treatments for depression and anxiety in the context of personality difficulties.

3. (3) To reflect on enhancing treatment for clients with personality difficulties via training workshops.

Microaggressions have been a topic of significant debate in the psychological and social sciences. Despite an extensive body of empirical evidence, numerous misconceptions persist. This paper deconstructs common misconceptions surrounding microaggressions and addresses their origins, underlying biases, and empirical refutations. We explain the mechanisms that cause and maintain microaggressions through a CBT lens. We examine widely propagated misconceptions, including claims that microaggressions lack scientific validity, are too subjective to measure, and are not indicative of racism or other forms of prejudice. Drawing on the substantial literature base, including validated psychometric scales, experimental studies, and cross-cultural analyses, we demonstrate that microaggressions are not only real but also have significant psychological and social consequences. Empirical evidence links microaggressions to outcomes such as depression, anxiety, and lower self-esteem, reinforcing their relevance in clinical, educational, and workplace settings. CBT models provide a useful lens for understanding how individuals navigate the psychological complexities associated with microaggressive behaviours, helping explain why some people resist acknowledging microaggressions and their consequences. Lastly, we highlight the importance of education for reducing the prevalence of microaggressions and mitigating their harmful effects. Our goal is to provide clinicians with correct information so that they may skilfully and empathetically help clients experiencing microaggressions, and to no longer accept microaggressions as a harmless, misunderstood, or dismissed phenomenon. By debunking these misconceptions, this work contributes to a more scientifically grounded understanding of microaggressions, emphasizing the necessity of continued research and intervention efforts to address the impact of discrimination in society.

Key learning aims

1. (1) Build awareness around the various misconceptions associated with microaggressions.

2. (2) Knowledge of why these misconceptions exist, where they came from, and why they are important to consider and refute.

3. (3) Refuting misconceptions with scientific explanations and evidence.

4. (4) Understand how CBT clinicians can better prevent and respond to microaggressions.

People with complex emotional needs (CEN) often receive poor care and struggle to access the evidence-based therapy they require. As part of community transformation, the Help to Overcome Personal and Emotional problems (H.O.P.E) team in Northumberland, and the Relational and Emotional Difficulties Service (REDS) in Cambridge, were set up to ensure that people with CEN could receive timely therapy without accessing secondary or tertiary services. Both services focus on providing adapted versions of dialectical behaviour therapy (DBT). The present study aims to understand the process followed to establish the two teams, identify whether they have been able to deliver accessible and acceptable treatment, and reflect on shared learning points for other services to consider. The study provides descriptions of the two service designs, further to quantitative and qualitative feedback from participants that completed treatment with the services. The results confirm that people in Northumberland and Cambridgeshire who accessed the services found the therapy to be acceptable and reported significant improvement in their ability to regulate their emotions, a decrease in symptoms associated with CEN, and a greater sense of progress towards achieving meaningful goals in their lives. However, in line with the broader literature, a high number of people dropped out and did not complete the interventions. The results suggest that the H.O.P.E team and REDS are providing acceptable and accessible evidence-based treatment for people with CEN. Reflections for future services to consider regarding reducing drop-out rates, the length of treatment, inclusion criteria, engaging people from minority groups and the use of online vs face-to-face therapy are provided.

Key learning aims

1. (1) Understand the process followed to establish two different CEN services in primary care settings.

2. (2) Identify whether two CEN services have delivered accessible and acceptable treatment.

3. (3) Compare how two CEN services are structured, and highlight shared learning points for other services.

The UK National Institute for Health and Care Excellence (NICE) recommends CBT for people with psychosis, yet many do not access therapies promptly, and duration of untreated psychosis predicts poorer outcomes. In addition to systemic service issues, it is likely that insecure attachment, common in people with psychosis, constitutes a key barrier to therapy. If we can articulate attachment patterns in terms of interpersonal beliefs and behaviours, we will be better placed to engage people in CBT. We used a cross-sectional design to examine theoretically predicted relationships between attachment style and (1) beliefs about self and others, (2) underlying assumptions, and (3) help-seeking intentions, across the psychosis continuum – in analogue and clinical samples. We recruited a general population analogue sample with elevated levels of non-clinical paranoia (n=172) and a clinical sample with self-reported psychosis (n=130). All completed standardised measures of attachment, beliefs about self and others, underlying assumptions and help-seeking. Regression analyses showed that insecure attachment predicted higher levels of negative self- and other-beliefs, and problematic underlying assumptions, and reduced help-seeking intentions, with some differences in patterns across analogue and clinical samples. Attachment is associated with CBT treatment targets and can inform psychological formulation and treatment. Our measure of assumptions may have been inappropriate for the clinical group. We conclude with public health, service level, and clinical implications to improve engagement and outcomes in CBT for psychosis.

Key learning aims

1. (1) Everyone with psychosis should have access to recommended treatments including CBT, but many do not.

2. (2) Insecure attachment is common in people with established psychosis or elevated levels of non-clinical paranoia, and may be a key barrier to accessing therapy.

3. (3) We show that insecure attachment is associated with (1) beliefs about self and others, (2) underlying assumptions, and (3) help-seeking intentions.

4. (4) Attachment style can inform CBT formulation and intervention, and wider service level and public health campaigns designed to improve engagement and outcomes for people with or vulnerable to psychosis.

Brief distress tolerance interventions aimed at improving ability to tolerate psychological discomfort are being used trans-diagnostically, by both clinicians and paraprofessionals. Such brief interventions, delivered by a range of professionals could help to bridge the current worldwide gap between demand for and availability of mental health support. Despite a good theoretical rationale for the effectiveness of distress tolerance skills, empirical evidence for stand-alone interventions is lacking. This report details an evaluation of a 6- to 8-week distress tolerance intervention delivered in a community mental health setting by clinicians and paraprofessionals, using routinely collected outcome data. The aim was to better understand data completion, the proportion of responders and any pre-intervention differences between responders and non-responders. Pre-intervention routine outcome measures were found to be reasonably complete, with good post-intervention follow-up. Distress tolerance specific measures were less complete. Where it was possible to calculate reliable change (n=163), 58.3% of clients were classified as responders to the distress tolerance intervention which is comparable to CBT outcomes, and response rate is improving over time. There was no evidence that clients were more or less likely to respond depending on their age, presenting problem, mood scores pre-intervention, referrer discipline or the role of the person delivering the intervention. Responders were found to have significantly poorer ability to tolerate distress pre-intervention compared with non-responders. Men were disproportionately likely to be non-responders which may indicate a need for improved access.

Key learning aims

1. (1) To increase practitioners’ understanding of distress intolerance as a factor that may sustain difficulties and serve as a valuable focus for intervention.

2. (2) To demonstrate the potential effectiveness of a brief psychological approach delivered by clinicians and paraprofessionals targeting distress tolerance in achieving meaningful, reliable change.

3. (3) To illustrate how services might identify which clients benefit most from a distress tolerance intervention to inform referral decisions and enhance client outcomes.

Body dysmorphic disorder (BDD) is a common, often debilitating condition that frequently goes undiagnosed and untreated. Limited training for mental health clinicians may contribute to this gap, but no study to date has systematically mapped BDD teaching within professional training courses. The current study aimed to establish the extent of BDD training provided to psychological therapists in the UK, comparing it with obsessive-compulsive disorder (OCD), a related condition with a similar population prevalence and impact. A cross-sectional survey design was employed. Surveys were sent to all UK Doctorate in Clinical Psychology (DClinPsy, n=32) and Post-graduate Diploma in Cognitive Behaviour Therapy (PgDip, n=30) courses, initially as a general request and then under the Freedom of Information Act. All courses responded. Teaching on BDD and OCD in DClinPsy and PGDip courses was summarised descriptively, and differences were assessed using z-tests of proportions. Results indicated that BDD is taught less frequently than OCD (61.3% vs 96.8% of courses) and for shorter durations (7.9% vs 60.0% provide more than 1 day of training). DClinPsy courses offer BDD training less often than PgDip (40.6% vs 83.3%) and most BDD teaching occurs within the adult stream. The current findings highlight a significant gap in BDD training within UK psychological therapy programmes, particularly DClinPsy courses, potentially contributing to under-recognition and under-treatment of BDD. These findings call for better integration of BDD into core curricula for mental health professionals, alongside the development and evaluation of low-resource training solutions than can be rolled out among the existing workforce.

Key learning aims

1. (1) To consider the barriers that individuals with BDD experience in accessing care.

2. (2) To recognise that BDD is under-represented in psychological therapy training courses.

3. (3) To consider ways of increasing BDD training, through curricula reform and through scalable, online programmes.

4. (4) To be aware of available BDD assessment measures and therapist CBT manuals, which clinicians can use to guide their practice.

Cognitive distortions are central to the conceptual and therapeutic framework of cognitive behavioural therapy (CBT), yet the existing taxonomy has remained largely unchanged since its development in the 1980s. This article proposes a novel addition to the distortions: the ‘Forever Fallacy’ defined as the tendency to project present discomforts, limitations or emotional states across imagined future timelines as if they were permanent and unchanging. Drawing on dual-process models of cognition, the Forever Fallacy is conceptualised as a heuristic, System A-driven distortion characterised by temporal fusion, stability projection and affective permanence. It differs structurally from established distortions like catastrophising or fortune telling through targeting the perceived duration and stability of anticipated future states rather than their content or likelihood. The article synthesises empirical research on affective forecasting, prospective cognition and temporal construal theory to ground the construct in established psychological science. Clinical illustrations demonstrate its presentation in anxiety, depression and existential overwhelm. Implications for case formulation are discussed alongside proposed adaptations to standard CBT interventions. Through articulating and operationalising the Forever Fallacy, this article contributes a theoretically coherent and clinically relevant extension to cognitive models of emotional distress, warranting future empirical validation and integration into therapeutic practice.

Key learning aims

1. (1) Define and use the ‘Forever Fallacy’: recognise it as the tendency to treat a current state as if it will not change, then apply it in formulation and practice by (i) naming the patient’s duration belief (‘it will always be like this’), (ii) mapping fluctuation with time-stamped ratings (for example, 0–10 every 30–60 s for 5–10 min) and (iii) running brief, time-limited behavioural tests to demonstrate change over time.

2. (2) Differentiate the Forever Fallacy from related thinking errors by focusing on time: it fuses the present with the future, assumes things will stay the same, and treats feelings as if they will last. Unlike catastrophising or fortune-telling, it concerns duration rather than how bad something is or how likely it is to happen.

3. (3) Use research on affective forecasting and construal level to explain why people tend to over-estimate how long and how strongly they will feel in the future and to mistake current states for fixed trajectories (Trope and Liberman, 2010; Wilson and Gilbert, 2003).

4. (4) Apply targeted cognitive behavioural therapy (CBT) and third-wave methods that restore a sense of time; for example, episodic future simulation, thought records with time columns, and decentring, and test change across sessions (Holmes et al., 2007; Teasdale et al., 2002a; Yamada et al., 2018).

5. (5) Set the construct within familiar theory and brain science: Personal Construct Theory and Schema Therapy; the Looming Vulnerability model of anxiety; the negativity bias; and default mode network (DMN), amygdala interactions and neuroplasticity, to guide formulation and mechanism-focused intervention (Kelly, 1991; Young et al., 2003; Riskind, 1997; Baumeister et al., 2001; Phelps and LeDoux, 2005; Etkin et al., 2015).

This model proposes that clinical complexity is defined with respect to treatment complications, not just client characteristics. In complex cases, there are significant barriers in the working alliance between the client and the therapist, and this limits the gains the client can receive. In any course of therapy, client, therapist, healthcare and contextual factors interact to facilitate or complicate the therapeutic process. Each participant has facilitative factors that are therapy-enabling, and complexity factors that challenge the therapeutic process. Some clients have multiple complexity factors and it is helpful to specify them and try to mitigate them. However, identifying clients as complex cases can overlook facilitative factors and take attention away from therapist and service variables. Overcoming alliance barriers relies on bringing attention to them, reflecting on the various factors that influence them, and communicating explicitly about them in supervision and therapy. Practical applications are explored for clients, therapists and services using a case example to illustrate the key points.

Practice research networks (PRNs) have been proposed as a mechanism to support continuous service evaluation and improvement in the field of psychological therapies. In theory, PRNs could help to generate high quality practice-based evidence that has potential to inform and improve clinical care. However, in practice, many obstacles pose challenges to the sustainability and impact of such networks. The UK Northern Talking Therapies PRN is an exemplar that has generated over 20 scientific publications over a decade of successful clinical-academic collaborations. This article distils key lessons learned over that time, to guide and promote the wider adoption of PRNs in psychological services.

Specific phobia of vomiting (SPOV) is a persistent, excessive fear of vomiting that is more prevalent in females, often begins in childhood and typically lasts 25 years before treatment is sought. It is a relatively neglected area of research, with most evidence consisting of single case studies. There are implications for the perinatal period, in particular the experience of pregnancy which for many involves symptoms of nausea and vomiting. However, there is a paucity of research on the experience of SPOV during pregnancy and currently no published treatment research. This study aimed to extend the existing literature by applying Veale’s (2009) protocol for SPOV to a pregnant client in her twenties. The intervention consisted of 12 one-hour face-to-face sessions and was effective in significantly reducing anxiety (GAD-7 reduced from 7 to 0), depression (PHQ-9 reduced from 6 to 1), impaired functioning (WSAS reduced from 20 to 4) and vomiting phobia (SPOVI reduced from 40 to 0).

Key learning aims

1. (1) To understand the impact of SPOV during pregnancy.

2. (2) To understand how to adapt Veale’s (2009) SPOV treatment protocol for a pregnant client.

3. (3) To learn how to carry out behavioural experiments and imagery rescripting related to SPOV during pregnancy.

This paper describes a single case study of a female asylum seeker presenting at a specialist clinic for women with female genital mutilation (FGM). The patient presented with post-traumatic stress disorder (PTSD) to multiple events due to her 45-year history of sexual and physical abuse. She also had intense feelings of being contaminated due to the sexual abuse. Within the cognitive model, a cognitive restructuring and imagery modification protocol was used to treat the patient’s feelings of being contaminated. After that, imagery rescripting was used to address the patient’s many PTSD re-experiencing symptoms. Clinicians can often feel overwhelmed when working with patients who present with multiple, traumatic events spanning many years; it is hoped that this case study helps clinicians to feel more confident about working with this client group and with women with FGM.

Key learning aims

1. (1) To be able to assess and treat survivors of multiple sexual assaults over many years using imagery rescripting.

2. (2) To learn how to use cognitive restructuring and imagery modification to treat feelings of being contaminated.

3. (3) For therapists to gain confidence with working with women who have experienced female genital mutilation.