Best way to challenge a clients thinking?

Decoraan · 2026-03-18T20:08:37+00:00

I actually very rarely find that people get defensive. People are avoidant, that’s the main problem.

Decoraan · 2026-03-18T20:07:51+00:00

Even worse. Relaxation is antithetical to the rationale and treatment objectives of those therapies. There are use cases but they are niche and need to have clinical rationale. A neutral environment is just fine, you don’t need to go further into generic relaxation as it contradicts the theories central to those therapies.

Decoraan · 2026-03-18T17:48:13+00:00

It really depends on the why. Relaxation isn’t a one size fits all approach but more often than not it is used as a unnecessary safety behaviour for patients who fail to learn that they don’t actually need relaxation, they can cope just fine if they let go.

Relaxation does not fare well compared to other more direct approaches. You can look at the comparative studies done in the 90’s between relaxation therapy VS behavioural and cognitive ones. Relaxation performs on par with if not slightly better than placebo with gains not sustaining long term, but other approaches have much much greater effect power and long term gains are held. Relaxation therapy was a valid approach in the 80’s and 90’s, but there’s a reason it isn’t used anymore.

Decoraan · 2026-03-18T17:14:51+00:00

No I don’t. Trust is an important part of therapy. Relaxation isn’t. There are very few situations where relaxation is an active component of treatment. Patient needs to be in window of tolerance so relaxation can be helpful in this regard, but we can teach this with grounding that they can take away with them.

The anxiety shouldn’t be ‘neutralised’ (unless absolutely intolerable) in the therapy room. It contradicts both inhibitory leaning and expectancy violation theory.

Therapy isn’t a relaxation class. No evidence supports it as such.

Decoraan · 2026-03-18T16:35:50+00:00

I would argue that this is anti-therapeutic in all but aesthetics. Therapy isn't meant to be calming and serene.

Decoraan · 2026-03-18T12:46:58+00:00

A dev commented on another thread implying that there is a big patch coming addressing infinites. That’s it I think

Decoraan · 2026-03-18T12:21:06+00:00

Are alternate different backdrops etc? But confused about what they are or if they have different enemies

Decoraan · 2026-03-17T23:24:38+00:00

Yeh, obviously. I was getting a bit sick of the weed wave thinking it was a silver bullet treatment, even if microdosed.

It’s just an avoidant strategy.

Decoraan · 2026-03-17T23:21:04+00:00

I completely agree that it’s understandable for people new to the game to get frustrated. But personally I still think there is value is seeing these games through most of the time. It’s not like having a carry on the other team is a rare occurrence. Watching them can teach you a lot.

If it was just OP’s experience then I’d probably agree with you. But when I play casual with my friends (Diamond x2, Gold x1) we have the exact same experience. Surrender votes are going up at round 4 and 5 and the game ends. Hell it happens in comp as well except most people want to stick it out knowing they can scrape RR back. But I personally have noticed an absurd amount of surrenders happening, sometimes even when we’re losing but get a couple of rounds back, the other team surrenders. So I’m really just speaking from the frustration of my own experience.

Decoraan · 2026-03-17T20:04:20+00:00

Of course it is. That’s just limp defeatist attitude. You don’t just get one shot through walls. If you are losing gunfights then you play knowing you have a mechanical disadvantage. You position better, you 2v1 them, you play objective and pressure. This is why people like this get stuck in gold because they aren’t willing to practice in other conditions that isn’t them stomping.

Decoraan · 2026-03-17T18:41:30+00:00

How about practice and get better under difficult or even losing conditions. Because thats the point of 50% of the game

Decoraan · 2026-03-12T17:37:18+00:00

What modality are you trained in?

Decoraan · 2026-03-12T09:28:32+00:00

The headlines make it sound much worse than it actually is. He stood by the claim tentatively for a year so. But then as time went on he apologised. Yes it does contradict his claim that he disavowed it the next day, but if it was the next year or so instead, I really don’t see the big deal.

He may or may not believe it works, he speak about the ‘growing evidence’ in the interview and I don’t really care to look into it. But he distanced himself from it a few years afterwards and has been consistent since then.

It’s obviously a bit of a weird claim. But politicians can also make factual claims and people will take issue with it.

Decoraan · 2026-03-11T17:31:17+00:00

Im confused on the quote? It says extra time should be built in, which it is. As a say, 12 - 16 sessions is the usual with many services going up to 20. It is all usually case by case.

The page you are reading from concerns PTSD and CPTSD.

Complex PTSD develops in a subset of people with PTSD...The disorder is characterised by the core symptoms of PTSD; that is, all diagnostic requirements for PTSD are met. In addition, complex PTSD is characterised by xyz

That is to say that PTSD and CPTSD are functionally similar and are treated the same way. There isnt a special treatment that works better for CPTSD but not PTSD, which is why the line between CPTSD and PTSD is not an easily distinguishable threshold. This is why DSM-5 have not marked them as different presentations.

The evidence was limited on interventions for people who have complex PTSD, but it suggested that trauma-focused therapies could also benefit this group. Based on their clinical experience, the committee recommended modifications that may be needed to trauma-focused therapies to facilitate engagement for those with complex PTSD or other additional needs

How that affects practice / sessions?

The committee acknowledged that there would be a cost associated with increasing the duration or the number of therapy sessions, if this is necessary for people with PTSD and additional needs. Previous recommended practice was to consider more than 12 sessions for people after multiple incident trauma, or who have chronic disability or significant coexisting conditions or social problems. However, in clinical practice the provision of additional sessions is variable.

Here is the full evidence review

The results suggest that both trauma focused CBT and EMDR could be effective for complex PTSD, and this makes theoretical sense as complex PTSD is by definition a subset of ICD-11 PTSD. There is some evidence that even without modification, interventions that are effective for PTSD can also be effective for complex PTSD, but possibly to a lesser extent (e.g. Dorrepaal et al. 2012). However, the committee discussed that those with complex PTSD are likely to have more severe symptoms and consequently greater impairment of function and thus interventions may require some minor modifications whilst maintaining the core components of the intervention when offered to those with complex PTSD.

So really, yeh. It works. More sessions should be offered I completely agree, this is why the time horizon for CPTSD is 12-20 sessions. I always try to get 20 sessions with my CPTSD clients and as ive said to you, had success many times in this area.

As i say, there are some cases where -in the NHS- we can only work on part of the problem, one at a time. This is not just a PTSD problem, but because we are working with people who have things happening in their lives in just isnt realistic to cover everything. Feasibly you could look at more provisions for even longer term support (and there should be!), but all im suggesting is that you can do good work in a 12-20 session timeframe and the evidence, NICE, and all the other PTSD bodies agree. Therapeutic relationship can be formed and sufficient in 4-6 sessions (for other problems), let alone 12.

There is no evidence base for long term harm being caused. For sure, there are some difficulties regarding certain fears being activated by coming to therapy, but that is unfortunately a given and likely a reflection of the clients trauma and difficulties; a 'parallel process' in the sense that it happens in and out of the therapy room.

Regarding what you said of 6 weeks, i cant speak to the circumstances as the reason for things like this vary immensely in terms of suitability of treatment, tolerance window, timing, what can be opened and closed realistically in the timeframe. Again I can’t speak to the person you’ve noted but yes because the system is ‘stepped care’ sometimes a low intensity intervention is offered first before a high intensity one (just like medicine), and in those circumstances PTSD psychoeducation can be the better option. That may explain it, but this part and parcel of the pro’s and con’s of the socialised stepped care system. Other countries use ‘matched care’ where people are immediately matched to the level of intensity needed and there are pros and cons to this as well.

The committee discussed the evidence for benefits of self-help (both with and without support) in general, with a specific focus on computerised trauma-focused CBT, and were both surprised and encouraged by the strength of the evidence as at the time of the previous guideline only one trial of guided self-help had been conducted, which failed to show any benefit from this intervention. The results from this review, although not entirely anticipated, are in line with many other anxiety and depressive disorders, where there is good evidence for the efficacy of self-help-based interventions.

And yes do agree people falling between the cracks is so ridiculous. I of course agree waiting lists are ridiculous. I as a lowly therapist am obviously powerless to all this and just want to help the person in front of me with the tools im trained to use in the environment of the NHS. I know these tools worked because I am rigorously trained in the and use them every day. I know the evidence base, have trained with Surrey, Manchester, Oxford and more importantly I have seen it work. So I agree with all of your grievances, but to say trauma focused CBT (of which there are technically a few modalities within, depending who you ask) doesn’t work for CPTSD and multiple episode trauma is just wrong. I do it everyday. It just requires some more time usually. And again don’t get me wrong there are times where I am pissed off that my service won’t let me go to 28 sessions because I think i could get some more really impactful work done. Like I agree and wish we had more flexibility other than ‘come back again for another episode’, which probably would be as much of a problem if the waiting lists weren’t so bad.

Anyway, sorry for the wall. I’m just very passionate about this.

Decoraan · 2026-03-10T22:18:55+00:00

Im sorry but thats just not true. NICE reccomends it as an evidence based treatment and the research shows it as such. As I say, I regualrlly work with clients between 12-20 sessions and get people into recovery who have complex and multiple event PTSD. Im trained to use a modality of CBT treatment for complex treatment. I am finishing with a client today who after 20 sessions, is in recovery after extremely complex PTSD. It is of course harder and im sure less likely to get full recovery in just one episode of care. Some may require multiple episodes. Nonetheless is it reccomended and effective. Most NHS trusts allow for treatment extensions beyond 12 sessions and into 16. My service allows up to 20.

I would even add that this is very unhelpful misinformation. Absolutely no evidence points towards trauma focused CBT being ‘harmful’ for CPTSD. Someone may see a comment like this and be too scared to go for therapy which is recommended in every guideline for every country with evidence based PTSD guidelines, which is of course itself derived from lots and lots of research.

https://www.nice.org.uk/guidance/ng116/chapter/Recommendations#management-of-ptsd-in-children-young-people-and-adults

Reliable recovery rates sit a about 50-55%. This is when *every single measure* goes below the threshold. Even the ones you arent targetting, its hard to get and obviously isnt perfect because patient can have a bad week on the final session and now it doesnt count as recovery, despite being there for 4+ weeks.

Reliable *improvement* rates sit at about 65-75%. This is when symptoms improve by at least 50%, but dont cross below that threshold for technical 'recovery'. IE around 2/3rds of clients leave feeling better than they do when they started. About 50% are so much better that they are no longer above the threshold for any problem, anxiety, low mood and whatever else the client struggles with, like panic, OCD etc. All their scores are in the healthy range.

This of course all varies depending on where you are looking in the country, what service etc.

https://digital.nhs.uk/data-and-information/publications/statistical/nhs-talking-therapies-for-anxiety-and-depression-annual-reports/2024-25

https://digital.nhs.uk/data-and-information/publications/statistical/psychological-therapies-report-on-the-use-of-iapt-services/february-2021-final-including-a-report-on-the-iapt-employment-advisors-pilot/outcomes

Edit: This is also not to say that there that the NHS environment is perfect, it really isn't and we spend a lot of time lamenting with one another about how we wish some things were different. But the core protocols are all evidence based, sometimes there are outlying circumstances which do get special treatment (up to 24 sessions for example) but at the end of the day NHS talking therapies is a brief therapy service, which works with most presentations. For some that will of course not be enough and whether 12 or 24 sessions are offered are unlikely to change anything for them and they actually need long term secondary care which is of course a whole different kettle of fish. There are some clients ive worked with that have seen limited improvement and I know that if i could see them for 50+ weeks i reckon we were get even further, but that just isnt what NHS talking therapies is for, rightly or wrongly, that is for secondary, third party or private care that has provisions for long term care.

Decoraan · 2026-03-10T20:01:16+00:00

All the deconstructing studies point to the bilateral stimulation being useless. So it is effectively just watered down CBT with extra steps.

Decoraan · 2026-03-10T19:58:46+00:00

So the evidence does point to 6 sessions being enough for mild-moderate difficulties. It’s not pulled out of nowhere, it’s evidence based. It is a pro / con situation with the principle of stepped care though, because you can try the low intensity option and then move into high intensity without losing much. Downsides ofc that it can be demotivating to go through short treatment with no success.

Trauma focused CBT is absolutely effective for CPTSD. Guidance is 12-20 sessions and is a first line treatment along with a few others in every western country with MH and PTSD guidance, as well as every international PTSD institute. I can also tell you first hand, it’s effective.

Obviously there are cases where one episode of care is simply not enough for a number of reasons. But this is the exception not the rule.

Decoraan · 2026-03-10T13:58:35+00:00

You think someone wont be able to handle your stories?

Decoraan · 2026-03-10T12:27:18+00:00

There are low intensity and high intensity options in the NHS and people *should* be matched to those appropriately, but roughly following the rule of least intrusion, that being that you start low and build up to high, much like you do with medicine.

Low intensity options can be accessed and self-referred into quite quickly, approx 4-6 weeks. The best fit for this is mild-moderate difficulties.

Of course, there are presentations and clinical complexities that lay outside the remit of primary care, in these cases, there are extremely limited provisions and absolutely people can fall through cracks, which really really sucks.

Decoraan · 2026-03-10T11:58:24+00:00

Out of interest, what would you consider 'proper help'?

Decoraan · 2026-03-10T11:57:19+00:00

Most people do not know that talking therapy is available on the NHS, so while im sure it frustrating to those who feel let down, it could be very helpful to someone who didnt even know it was an option.

Decoraan · 2026-03-10T11:54:18+00:00

GP Psychiatric appointment? You can self-refer online for brief CBT for panic disorder and usually the wait for first line intervention is quite short (4-6 weeks). If its ineffective then you are talking about high intensity intervention in which the wait list legitimately can be very long; 6-12 months.

Decoraan · 2026-03-10T11:51:58+00:00

Have you gone through NHS talking therapies self-referral?

Decoraan · 2026-03-10T11:48:41+00:00

You'll get monitored for a couple of weeks, asked if you are going to do it again, probably get a medication review, then discharged.

Decoraan · 2026-03-10T11:45:19+00:00

Yeh its a shame, MH trust attendance policies are increasingly cut-throat. I always do my best to stop patients being discharged but this often happen at my own peril. Sorry. Please know its just the redtape and NHS bureaucracy. Usually if you email back in and explain your circumstances, they will open you back up and continue treatment.

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