Controversial Corner: Why some therapies suck for PTSD - and why people still do them

The research evidence reflects that (only four therapies) have a strong evidence base to treat PTSD. Why then are people still doing supportive counselling, equine therapy, cold water therapy, or the latest new craze? And why will some therapists 'hold space' for you for years without moving you forward?

Our clinicians at Strength Within can get a little feisty when it comes to talk about what makes an effective PTSD treatment. Our founder, Aleesha, can go from laughing at a Seinfeld quote to standing on her soap box about the dangers of the wrong therapy in three seconds flat! There's a very good reason for this: We have seen good therapy, and we have seen the danger of the wrong therapy.

While many of our clients have been in the 'early stages' of PTSD, a great many more were decades if not more from the event that led to their PTSD. As such, they were not new to therapy. Some have spent years talking to well-meaning professionals about their symptoms, their stress, and how difficult things have been since the trauma. Yet they didn't feel functionally better - and because they'd been 'doing therapy' for so long, they held a strong - but incorrect - belief that they were 'unfixable'. As a result, they were not living the lives they wanted to be, and were feeling hopeless about the future.

But here's the thing: talking about how hard life has been since the trauma is not the same thing as treating the trauma itself.

In trauma therapy we sometimes say, only half jokingly, that you can spend ten years talking around a trauma without ever actually touching it.

Real PTSD treatment starts when the work gently but deliberately turns toward the memory, the beliefs that grew around it, and the avoidance that has been keeping it locked in place.

That’s where recovery begins.

So why do some people end up doing “treatments” that don’t help them progress, they just hold them steady – or worse, send them backwards? The answer might be a little controversial or uncomfortable. We need to address something that can cause confusion both for less experienced clinicians, and for patients.

Good Trauma Therapy Can Be Hard

Evidence-based PTSD treatments work. But they’re not always comfortable – and are frequently uncomfortable. Many people will feel worse before they feel better, and if their clinician has not helped them to understand why this is (and why it means the treatment is working), they can drop out of therapy.

But if we stop and think for a moment, we'd realise that of course it might feel painful at first. If you’ve ever started a new fitness routine after a long break, you know that you don’t leave the gym feeling physically strong – you leave feeling depleted, and sometimes sore in the days after. But as you build those muscles and strength, the workout gets easier.

Treating PTSD works similarly, but instead of muscles, it the neurochemistry you have developed as a way to protect yourself. Processing trauma means approaching memories and beliefs that people have often spent years trying to push away. There’s no denying it – this is hard. It takes courage from the client. And it takes skill from the clinician.

The payoff is that something extraordinary occurs when trauma begins to be processed properly: The brain stops feeling like the threat is current, and starts treating the trauma as what it is – something that happened, rather than something that is still happening.

This can be a hard few weeks or months for people, so it makes sense that people are wary. But most people would probably rather a hard few weeks or months – and then feeling noticeably better – that going to therapy for years just to ‘hold on’. Additionally, some things people do for PTSD that they think are ‘treatments’ are actually making their symptoms worse.

Supportive Counselling

Supportive counselling is the term used to describe a therapeutic conversation that doesn’t fit into a specific treatment modality. Done well, it provides empathy, validation, and a safe place to explore challenging thoughts, feelings and memories.

All of those things matter, especially when someone is so low they can’t see a way out – in those moments we can’t always start a true ‘treatment’, we need to care for someone where they’re at to ensure they're in a healthy place to start their treatment.

Supportive counselling by itself and without clear objectives is not a treatment for PTSD, and is likely to make the symptoms worse in the long term.

PTSD isn’t just about feeling distressed after something bad happens. It’s a condition maintained by a few very specific psychological processes:

1. Avoidance of trauma memories and reminders

2. Holding tight to unhelpful beliefs about the trauma (“It was my fault”, “The world isn’t safe”)

3. Fear responses that keep firing within our brains and body even though the danger has passed

Supportive counselling usually focuses on listening and emotional support. That’s valuable, but it doesn’t systematically target these processes.

And if therapy never actually helps someone physically and cognitively process the trauma, avoidance will continue in the background, because avoidance feels good in the short term. But for PTSD it’s basically petrol on the fire.

This is why treatment guidelines consistently recommend trauma-focused therapies, not purely supportive approaches, as the primary treatment for PTSD. That’s not to say that you won’t feel supported, and validated, and heard while undergoing PTSD treatment. It just won’t be the only thing we do.

In order to work, effective trauma therapy doesn’t solely help people feel supported. It helps the brain learn that the trauma is over.

Equine therapy, Art therapy, Ice bath therapy, etc

There are many ‘adjunct’ therapies available to those with PTSD. However, it’s important to remember that these therapies, camps or activities are often what are referred to as ‘adjunct’ therapy. That is to say, while they are often found to have positive outcomes in that people leave feeling ‘better’, there is no evidence that they reduce the functional impact of PTSD in the medium to long term. If you have access to these and find them helpful, please utilise them! Just remember they are not the semi-permanent to permanent measure that the evidence based treatments have been found to be. Think of them as the difference between getting a massage to help your back pain, versus building muscles so your back stops hurting at all.

A Quick Word About “Holding Space”

If you spend enough time around therapy culture (or TikTok!), you’ll eventually hear the phrase “holding space.” And of course being present, compassionate, and emotionally attuned absolutely matter! All therapists should be doing this regardless of the treatment type they use.

But if therapy for PTSD stops at “holding space”, we’ve probably missed the point.

Trauma therapy isn’t just about sitting with pain: It’s about helping people move through it.

That requires skill, structure, and sometimes a willingness to gently challenge avoidance.

Which, to be honest, is a lot harder than nodding sympathetically for 50 minutes.

So here comes the controversial part: Why do we - patients and therapists - sometimes keep doing these 'treatments' that are more of a bandaid and less of a suture?

Because it’s easier. It is easier on the client to not have to become distressed. It is easier on the clinician to not have to ask them to do their homework or discuss things that upset them. It’s more comfortable to discuss the most recent week’s random life stressor than to challenge a belief we’ve held for twenty years. But there is a real danger to this approach – and it is not just that the person ‘won’t get well’. It’s that these sorts of approaches can make someone worse.

When Therapy Accidentally Reinforces Avoidance

There is an uncomfortable reality we need to mention if we hope to work successfully to treat PTSD. Many people with PTSD spend years in therapy without ever actually receiving trauma treatment. They may attend weekly sessions, talk about how their week has been, process current stressors, and feel genuinely supported by their therapist.

But if the trauma itself is never systematically addressed, the core PTSD mechanisms often remain untouched. The person learns strategies to cope with the impacts of PTSD – but doesn’t get the professional support they need to actually reduce these impacts. The person likely feels 'safe', but is not moving forward.

In these situations, therapy can unintentionally become another form of avoidance. Not deliberately, and not because the therapist doesn’t care - but because the work that actually treats PTSD can feel confronting for both client and clinician. PTSD treatment sessions are mentally and physically draining, not just for the client but also the clinician. Is it any wonder that some less confident psychologists may be happy to offer ‘less invasive’ measures if it keeps the client coming back?

But if you are using your time and money to see a clinical psychologists, you deserve more than supportive conversations about life stressors. Yes, that conversation might feel easier that processing the worst thing that’s happened to you or someone you love – but the research is clear: avoiding trauma memories tends to maintain PTSD, even when that avoidance happens politely inside a therapy room.

Good trauma therapy is compassionate and supportive. But it is also active, structured, and willing to gently approach the very material people have spent years trying not to think about. There may be times in therapy where you tell your therapist you don’t like them – just like you might not like your physiotherapist, or driving instructor, or strength coach, when they ask you to do something a little outside your comfort zone to help you get the skills or strength or flexibility you need.

That’s why PTSD treatment is hard, that’s why clinical psychologists undertake specialist training to do it, and that’s where the real change happens. Much like in the gym – growth rarely occurs in our comfort zone.

PTSD treatment shouldn’t be mysterious.

We know what works.

And when people are given access to evidence-based trauma therapies, recovery is not only possible - it’s common.

The real challenge isn’t discovering better treatments; It’s making sure people actually receive the ones we already know work.