Basal Exposure Therapy

1. Introduction

Version followed: Heggdal, Basal Exposure Therapy (BET): Basic principles and guidelines, Treatment Manual 1, v2.0 (10 Oct 2012, Vestre Viken HF, Blakstad). Filled in from the published service description (Heggdal, Fosse & Hammer, 2016), the Norwegian implementation manual v1.1 (Heggdal & Svergja), Hammer & Heggdal (2011) and Hammer et al. (2018). The original Norwegian manual (Heggdal, 2008) is not drawn on [uncertain].

What it is. Basal Exposure Therapy (BET) is not a stand-alone outpatient psychotherapy. It is a whole-ward treatment model run by a multidisciplinary team, developed by psychologist Didrik Heggdal and colleagues at Blakstad psychiatric hospital (Vestre Viken Hospital Trust, Norway) from 2000 onwards. The manual calls it a "third-generation" cognitive-behavioural approach. It was built for adults with severe, long-standing and composite disorders: schizophrenia-spectrum, bipolar, PTSD and dissociative disorders, and complex personality disorder. These patients typically have chronic self-harm or suicidality, repeated long admissions, polypharmacy, a lot of past coercion, a GAF below 35, and are seen as "treatment-resistant". [source: Heggdal 2012; Heggdal, Fosse & Hammer 2016; Heggdal IASA 2018 slides]

How change happens. BET treats the condition as a phobia of the patient's own affective arousal, which the authors call "basal phobia". Underneath is "existential catastrophe anxiety": the expectation of falling apart, dissolving, being swallowed by emptiness or being stuck in endless pain. Self-harm, dissociation, food restriction, inactivity and emotional numbing are understood as ways of avoiding that feared state. Repeated help from the health system (restriction, heavy medication, coercion) can keep the avoidance going. The service is organised as a predictable "secure base" (Bowlby). From that base the patient chooses to stop avoiding and to expose themselves, step by step, to the feared inner experiences, and learns that the catastrophe does not happen. The aim is second-order change, meaning a different relationship to inner pain rather than less pain. The authors place the mechanism within phobia treatment, systematic desensitisation, habituation and inhibitory learning (violating expectations, varying contexts), with the Dynamic-Maturational Model of attachment (DMM) used to tailor the approach to each patient. [source: Heggdal 2012 §3; Heggdal, Fosse & Hammer 2016]

Context for adopters. BET is in Domain V because it is presented as a rights-based, low-coercion service. A 2021 WHO catalogue of good-practice services chose it as one of three inpatient services worldwide, the Council of Europe has also listed it, and the UN Special Rapporteur on disability rights cited it after a 2019 visit [source: Psykologtidsskriftet 2021 news item; the exact WHO document title was not confirmed, uncertain]. Former patients have published serious accounts of harm (Kjus 2021; Mjøsund et al. 2022), and this guide builds those risks into sections 4–5. In July 2024 the Vestre Viken clinic director recommended ending the open-door inpatient section in its 2018 form, citing a waiting list of about 1.5 years among other reasons, and looking into an outpatient or outreach BET service instead. No final decision was found [source: Helse Sør-Øst note to HOD, 4 Jul 2024; Vestre Viken user council protocol, 10 Sep 2024; current status uncertain].

Licensing and certification. No certification or licensing scheme was found. The implementation manual describes about 16 days of support from an external assistance team spread over at least one year, alongside a local implementation team. It frames fidelity as "program adherence" without formal fidelity measures. Clinicians should not present work as "BET" unless they are trained by, or partnered with, the Vestre Viken BET team [source: Heggdal & Svergja impl. manual v1.1; the guidance on use of the name is synthesis].

2. Framework

Setting and team [source: Heggdal, Fosse & Hammer 2016; Hammer et al. 2018; Helse Sør-Øst 2024]

• Original setting: 6 BET beds inside a locked 12-bed psychosis ward, with 13.5 full-time staff (1 psychiatrist, 2 psychologists, nurses and milieu therapists). From 2018 BET ran as an independent "open-door" section taking planned referrals from all of Norway.
• Per-patient treatment team: a team coordinator, a responsible psychologist or psychiatrist (who holds legal and treatment responsibility and decision authority), and 2–3 co-therapists (nurses or milieu therapists).
• Length: individualised. The 2016 cohort averaged about 13 months (range 2–72). By 2018 the average was under 6 months, down from about 2 years at the start.

Standing weekly format [source: Heggdal, Fosse & Hammer 2016; Heggdal & Svergja v1.1]

• Daily individual therapy with one of the team's therapists. Therapists rotate on purpose so that contexts vary and the process does not become static.
• A 5-minute focus session every morning (set one concrete challenge for the day) and every evening (reflect on what was learned).
• A weekly plan that mirrors an ordinary working week. The patient is responsible for carrying it out.
• A weekly psychoeducation group, explicitly not group therapy. One session a month is led by a former BET patient.
• The patient takes part in their own treatment and team meetings. The staff team uses reflecting teams throughout.
• Usually 2–3 sessions with close relatives. Routine coordination with the GP, the outpatient therapist and municipal services to prepare for discharge.
• Medication is reviewed weekly by the team.

Pre-admission [source: Heggdal, Fosse & Hammer 2016; Hammer et al. 2018]

• Inclusion: GAF below 35 that is persistently low, falling or swinging sharply; a qualifying diagnosis; past outpatient and inpatient treatment without lasting improvement.
• Exclusion: personality dominated by persistent hostility; IQ below 70; extensive substance misuse combined with violence and marked cognitive impairment; organic brain disorder (with exceptions); emotionally unstable personality disorder as the only diagnosis, unless the history is long and turbulent with repeated dramatic suicide attempts.
• The medication discussion starts at the assessment interview, weeks or months before admission.

Phases. The manual gives five phases. The 2016 paper groups them into three: engagement, exposure and acceptance, and consolidation. [source: Heggdal 2012 §8; Heggdal, Fosse & Hammer 2016]

Running across all phases [source: Heggdal 2012 §4, §6]

• Complementary External Regulation (CER; Norwegian KER): three regulation modes, switched by team decision (section 4).
• Five levels of mental functioning: fragmentation, polarisation, beginning refinement, unstable refinement, stable refinement. The team tracks progression and regression at each level and adjusts how much challenge to give. Regression returns the team to Phase 1 or 2 tasks. The alliance "must be built and rebuilt".
• Progress marker: a 0–3 exposure rating (0 none, 1 intermittent, 2 systematic graded, 3 flooding), given independently by two clinicians who know the patient [source: Heggdal, Fosse & Hammer 2016].

3. Guiding principles

[source: Heggdal 2012 §2–5, §7; Heggdal, Fosse & Hammer 2016; Heggdal & Svergja v1.1; Hammer & Heggdal 2011, unless marked]

• Health means willingness, not freedom from pain. Success is measured by how the person relates to and accepts their emotions, not by how much pain is left.
• Compassion, equality, respect. Treat the patient as an equal and as a responsible agent who shapes their life through choices.
• The patient is a free agent (existential stance). Frame avoidance and exposure as choices, including the choice to keep avoiding and accept continued external regulation.
• Avoidance is the problem; exposure is the solution. Read symptoms and impairment as consequences of avoidance, and steer every intervention towards non-avoidance.
• Fear and pain are not removed. Do not soothe, fix, advise or take distress away during under-regulation. Wait for the patient's own coping attempt.
• Exposure is always chosen, never forced. Invite, explain and wait. A refusal is a valid choice that delays change; it is not a breach.
• Minimise force. Coercion is a failure mode to reduce. When life or health is in immediate danger, act at once under ordinary medical and legal procedures.
• Validate the feeling, not the content. Acknowledge that the experience is real for the patient without endorsing their account of events or their demands.
• Speak for yourself, and allow that you may be wrong. Offer observations and interpretations, never "the truth" about the patient.
• Don't dilute validation. End a validating statement without adding a question or reassurance, so attention stays on the feeling.
• Validate appeals, demands and threats instead of acting on them. Name the feeling under the appeal. Do not let distress-driven escalation change the plan.
• Focus on observable behaviour, not motives. Talk about what the patient does, such as posture, breathing, speech and self-harm, not why.
• Accept ambivalence and resistance. Treat them as part of the work, not as disruptions.
• Splitting is a developmental phase. Accept the role the patient gives you (idealised or devalued) instead of correcting it, and get support from colleagues.
• Counter-transference is data. Staff reactions can reveal the patient's attachment strategy or show that the process is drifting.
• One voice. Every view is heard; once the team decides, everyone carries the decision out loyally across shifts, weekends and holidays.
• Clear responsibility. Legal responsibility stays with the responsible psychologist or psychiatrist. Over-regulation needs a coordinated team decision.
• Vary the context. Rotate therapists and settings so learning generalises (inhibitory learning).
• Tailor to attachment strategy. Use the DMM to predict regression and to pitch the CER, for example the difference between Type A and Type C strategies [source: Heggdal IASA 2018 slides; detail thin, uncertain].
• Unexpected, matter-of-fact clarity ("BET rhetoric"). Say plainly that the patient has a choice, often by saying the opposite of what they expect to hear [source: Heggdal & Svergja v1.1].
• Medication is secondary to psychotherapy. Reduce it collaboratively as the patient improves.
• The patient gets full credit for change. Attribute gains to the patient's own self-exposure to build self-efficacy.
• Safety counterweight [synthesis]. Former patients describe principles applied rigidly as cold, scripted and abandoning (Mjøsund et al. 2022; Kjus 2021). Keep warmth, genuineness and predictability ahead of model fidelity, and keep checking whether BET still fits this patient.

4. Intervention inventory

Each entry cites its sources. Where the sources name a procedure but give no steps, the steps are marked [synthesis]. Example language is illustrative unless it is in quotes with a citation.

4.1 Pre-admission assessment, selection and informed choice

• Purpose: Decide whether BET fits, and start the alliance and the medication discussion before admission. [source: Heggdal, Fosse & Hammer 2016; Hammer et al. 2018]
• Steps:
  1. Check the inclusion and exclusion criteria (section 2) and review the full treatment history, including past coercion and polypharmacy.
  2. Review the patient's experience of each medication: effects, side effects, dependence risk. Ask about their own wishes for medication.
  3. Explain the model: basal phobia, avoidance as the problem, chosen exposure, and the phases.
  4. [synthesis, following Mjøsund et al. 2022] Give balanced information. Say that the treatment is demanding, that some patients get worse, that therapists rotate, that staff will not take pain away, and how self-harm is handled. Make clear the patient can say no without losing access to other care.
  5. [synthesis] Do a standard suicide risk assessment and record an agreed safety plan before admission.
• Example language (illustrative): "In this programme staff won't try to take your painful feelings away. We'll help you practise letting them come. Some people find that hard and some get worse for a while. Saying no to BET won't close any other door for you."
• Watch for: a patient who agrees because they feel this is a "last chance". Kjus (2021) describes being offered only BET or lifelong illness. Treat that as coerced consent and slow the decision down [synthesis].

4.2 Psychoeducation about the model (individual and group)

• Purpose: Give the patient a shared language (avoidance, existential catastrophe anxiety, exposure, functional diversion, self-exposure) and explain the paradox that facing fear reduces it. [source: Heggdal 2012 §8; Heggdal, Fosse & Hammer 2016]
• Steps: (1) In Phase 2, explain Phases 2–4 to the patient. (2) Hold a weekly psychoeducation group, not group therapy, covering the model's concepts. (3) Once a month, have a former BET patient lead the group. (4) Link habituation to the expectation of catastrophe going down over time. The order of topics in the group is not published [uncertain].
• Example language (illustrative): "Your mind has learned that strong feelings mean you'll fall apart. Each time you avoid a feeling, that belief gets stronger. Each time you let the feeling come and you're still here, it gets weaker."
• Watch for: the patient agreeing out loud while their behaviour does not change. The manual takes adherence, not words, as the sign of agreement.

4.3 Building the working alliance

• Purpose: Reach agreement on two premises: fear and pain cannot simply be removed, and the patient genuinely wants life to be different. [source: Heggdal 2012 §8 Phases 1–2]
• Steps:
  1. In Phase 1, "see" the patient, reinforce functional behaviour, and expect them to state their needs directly.
  2. Name and validate attempts to escape. Gently challenge the hope that someone else will take the pain away.
  3. Use open questions, reflections and validation, grounded in the view that symptoms come from avoidance.
  4. Present the choice: keep avoiding, or work with staff.
  5. Accept ambivalence. Rebuild the alliance after every disengagement.
  6. Use supervision to manage your own reactions.
• Example language (illustrative): "I can't take this pain away, and I don't think anyone can. What I can do is stay with you while you find out what happens when you stop running from it. Is that something you want?"
• Watch for: the alliance resting on the model rather than on the relationship. Mjøsund et al. (2022) found that strong loyalty to the model could overshadow the alliance [source].

4.4 Bounded validating communication (validation without reinforcing regression)

• Purpose: Communicate "I see you" and create a relational space for the feeling. This is the manual's "first aid" for self-regulation. It turns diffuse bodily discomfort into distinct feelings the patient can name, and loosens rigid reactions. It is the main tool of under-regulation. [source: Heggdal 2012 §5; Heggdal & Svergja v1.1; Hammer & Heggdal 2011]
• Steps:
  1. Notice the feeling from what you observe.
  2. Name it tentatively and in the first person ("I").
  3. Stop there: no question, reassurance, advice or problem-solving.
  4. Stay present.
  5. Validate the feeling, not the content or the demand.
  6. Avoid secondary reinforcers of regressive behaviour, such as extra attention that follows only escalation.
• Example language: "I may be wrong, but to me it seems that you are sad." [quote: Heggdal 2012 §5.3]. Illustrative: "It looks to me like you're furious with me right now."
• Watch for: signs it is working include more precise naming of feelings, less rigidity, and calmer bodily arousal. Signs it is failing: patients in Mjøsund et al. (2022) experienced repeated formula phrases as mechanical and distancing. Vary your wording, stay genuine and let warmth show [synthesis].

4.5 Invitational validating communication (for alexithymia)

• Purpose: A version of validation for patients who have little ability to describe their inner life in words. [source: Heggdal & Svergja v1.1; procedure not detailed, uncertain]
• Steps [synthesis]: Offer more scaffolding than in 4.4. Name bodily signs you observe, offer two or three possible feelings, and leave room for the patient to correct you.
• Example language (illustrative): "Your shoulders have gone up and you're breathing fast. I wonder if that's fear, or maybe anger. I might be wrong."
• Watch for: the patient correcting or refining your guess, which is a sign of growing affect awareness.

4.6 Responding to appeals, demands and threats

• Purpose: Avoid rewarding escalation while still recognising the distress behind it. [source: Heggdal 2012 §4.1, §7.3; Hammer & Heggdal 2011]
• Steps:
  1. Stay calm and collected.
  2. Validate the feeling under the appeal (4.4).
  3. Do not act on the demand and do not change the plan because of the escalation.
  4. If the patient brings a coping idea, respond in a solution-focused way (4.7).
  5. Hammer & Heggdal (2011) say that threats of suicide are met with this validating stance rather than detailed risk questioning. Risk flag: this departs from current standard practice. See 5.6 [synthesis].
• Example language (illustrative): "You're desperate for me to fix this, and it feels unbearable that I'm not."
• Watch for: appeals and threats becoming less frequent, and direct statements of need replacing them.

4.7 Solution-focused interventions

• Purpose: Build functional choices by attending to the coping the patient already uses. This is the second main tool of under-regulation and the core of consolidation. [source: Heggdal 2012 §4.1, §8; Heggdal & Svergja v1.1]
• Steps: (1) Notice any functional coping attempt, however small. (2) Ask about it concretely: what the patient did and how. (3) Reinforce it and give the patient credit. (4) Invite them to repeat it and apply it elsewhere.
• Example language (illustrative): "Last night you sat with that dread instead of cutting. What did you do to make that possible?"
• Watch for: the patient starting to describe their own strategies without being prompted.

4.8 CER mode 1: Under-regulation (default)

• Purpose: The everyday stance. It treats the patient as an equal who is responsible for their choices and pushes them to use resources they have not been using. [source: Heggdal 2012 §4.1; Heggdal, Fosse & Hammer 2016; Heggdal & Svergja v1.1; Hammer & Heggdal 2011]
• Steps:
  1. Keep daily life normal, with personal freedom balanced by accountability: the patient keeps appointments and tells staff when plans change.
  2. Staff do not solve problems, advise or relieve distress. They wait for the patient's own coping attempt.
  3. Use validation (4.4) and solution-focused interventions (4.7).
  4. Hand over responsibilities such as the weekly plan. One former patient reports being asked to manage his own pill organiser (dosett).
  5. Make the setting less predictable where that helps, so the patient has to find new coping strategies.
• Example language (illustrative): "That's your call. Let me know what you decide."
• Watch for: under-regulation can feel unsafe, especially at the start (Hammer & Heggdal 2011). Responsibility handed over too fast and too heavily was experienced as staff abdicating responsibility (Mjøsund et al. 2022). Transfer responsibility in steps, with support [synthesis].

4.9 CER mode 2: Instrumental external regulation (acute danger)

• Purpose: Protect life and health when there is a clear threat or an injury. [source: Heggdal 2012 §4.2, §7.3; Heggdal & Svergja v1.1]
• Steps:
  1. Act at once under medical procedures and formal legal rules.
  2. Keep the focus on the physical injury. Offer the patient the choice to cooperate.
  3. Keep verbal contact to the medical care. The manual says the cause of the injury and the patient's plans are not explored during the incident.
  4. Run no therapeutic interventions at the same time.
  5. Once the situation is resolved, return to under-regulation.
  6. The team reviews the event afterwards, without the patient.
• Example language (illustrative): "I'm going to look at the wound now. Can you hold your arm out for me?"
• Watch for: medical care that turns too brief or too cold. Not exploring the cause during the incident must not replace a structured risk review afterwards (5.6) [synthesis].

4.10 CER mode 3: Over-regulation (motivating standstill)

• Purpose: A back-up used only after repeated regression, when self-regulation keeps failing and life or health is at risk. It protects the patient while removing what keeps regression going. [source: Heggdal 2012 §4.3, §8; Heggdal, Fosse & Hammer 2016; Heggdal & Svergja v1.1; Hammer & Heggdal 2011]
• Steps:
  1. The team makes the decision together, under the responsible clinician.
  2. Apply close behavioural control and empathic presence beyond what a standard risk assessment would require. This can cover the whole life situation or only some areas.
  3. Slow everything down and keep stimulation low. The intended result is boredom and restlessness.
  4. Stay friendly and warm, and do not use force.
  5. Wait for the patient to start a "coping-dialogue" and propose concrete functional alternatives to destructive behaviour.
  6. Return to under-regulation as soon as the patient takes that initiative.
  The sources do not say how long, in which room or with how much contact [uncertain].
• Example language (illustrative): "We'll keep things very simple and close for now. Whenever you're ready to talk about how you'll keep yourself safe, I'm here."
• Watch for: this mode must stay within the jurisdiction's mental-health law on restrictive measures, with legal decisions documented where they are required. Monitor it for drift into punitive isolation, and set a review interval [synthesis].

4.11 Calibrating challenge to level of mental functioning

• Purpose: Match the intervention to the patient's current level and expect regression under high arousal. [source: Heggdal 2012 §6; the manual's table is laid out ambiguously, so the mapping below is the most consistent reading, uncertain]
• Steps: Assess the current level, then adjust:
  • Fragmentation/psychosis: validate the fear of chaos; reduce stimulation; be clear and predictable; use general external regulation.
  • Polarisation (low-functioning borderline): validate the good/bad and secure/insecure experience; accept being the one who limits autonomy, and stay empathic.
  • Beginning refinement: when arousal is high, validate the contradictions; let splitting play out in daily life; offer "objects" that can stand for good or bad; make staff roles clear.
  • Unstable refinement: present the relationship as having both good and bad sides; validate integration; praise nuanced thinking; offer alternative perspectives when arousal is low.
  • Stable refinement: praise how the patient handles interpersonal challenges; ask open questions that invite nuance; accept short regressions when arousal is high.
• Example language (illustrative, polarisation): "Right now I'm the bad one who won't let you go out, and you hate me for it. That makes sense to me."
• Watch for: movement up the levels, which is progression and the cue to raise the challenge.

4.12 Daily focus sessions (morning and evening)

• Purpose: Turn each day into one chosen exposure or coping challenge and consolidate what was learned. [source: Heggdal, Fosse & Hammer 2016; Heggdal & Svergja v1.1]
• Steps: Morning, about 5 minutes: the patient names one specific challenge for the day, and staff help make it concrete. Evening, about 5 minutes: reflect on what happened and what was learned. The patient owns the focus.
• Example language (illustrative): Morning: "What's the one thing you'll practise not avoiding today?" Evening: "What did you notice when you stayed with it?"
• Watch for: patients in Mjøsund et al. (2022) found focus sessions confusing and anxiety-provoking. Explain the purpose, give examples, and accept small targets [synthesis].

4.13 Patient-owned weekly plan

• Purpose: Build structure that mirrors a working week while placing responsibility for carrying it out on the patient. [source: Heggdal & Svergja v1.1]
• Steps [synthesis]: The patient drafts the week, including therapy, focus sessions, group, chores and activities. Staff ask how each part will be done. Deviations are discussed in solution-focused terms, not sanctioned.
• Watch for: plans that are empty or overloaded. Either can be avoidance.

4.14 Mapping and exploring avoidance (including existential catastrophe anxiety)

• Purpose: Phase 3. Make avoidance and the underlying catastrophe fear visible before exposure starts. At this stage the patient is only asked to become aware. [source: Heggdal 2012 §8 Phase 3; Heggdal, Fosse & Hammer 2016; Heggdal & Svergja v1.1]
• Steps:
  1. Observe and name avoidance in observable channels: physical habits, posture, breathing, speech patterns, intellectualising, externalising, and behaviours such as self-harm, dissociation, food restriction, inactivity and numbing.
  2. Separate conscious avoidance, which is chosen even when it feels necessary, from automatic avoidance, which is affect-driven and not yet a choice.
  3. Explore what the patient fears would happen without the avoidance. This usually leads to falling apart, emptiness, or endless pain.
  4. Offer this as an observation, not a verdict, and validate the need for the avoidance.
  5. Present the choice: examine the avoidance with staff, or accept continued external regulation.
• Example language (illustrative): "I notice that when we got close to your sister, you started talking very fast about the medication. I might be wrong, but it looked like a way of stepping away. What do you imagine would happen if you didn't step away?"
• Watch for: the manual notes that a constant focus on avoidance feels invasive. Patients in Mjøsund et al. (2022) felt that all their choices, including knitting or watching TV, were labelled avoidance with no room for discussion (also Kjus 2021). Keep the label negotiable and make room for functional diversion (4.16) [synthesis].

4.15 Graded exposure (systematic desensitisation) to affective arousal

• Purpose: Phase 4 core. The patient chooses to stop avoiding and lets the feared feeling and existential catastrophe anxiety come, so the expected catastrophe is disconfirmed. [source: Heggdal 2012 §8 Phase 4; Heggdal, Fosse & Hammer 2016; Hammer et al. 2018; Heggdal & Svergja v1.1]
• Steps:
  1. Confirm consent for this step. Exposure is always the patient's choice.
  2. Pick an inner experience the patient usually avoids, such as sadness, anger, guilt, emptiness or the urge to self-harm.
  3. The patient chooses not to use avoidance and stays with the feeling while you stay present and validate.
  4. Practise raising and then lowering arousal, so the patient learns they can control the intensity. The patient may choose to avoid again afterwards.
  5. Treat each exposure as a simple behavioural experiment: what was predicted, and what actually happened.
  6. Vary therapists, places and times so the learning generalises.
  7. Rate exposure from 0 to 3 over time.
  Hammer & Heggdal (2011): exposure "is rarely dramatic" and "the drama happens on the inner level" (translated).
• Contraindications and safety [synthesis]: Defer exposure during acute psychosis or fragmentation, where the manual instead advises reducing stimulation. Also defer when self-harm risk is acute and unassessed, and when the patient is consenting under pressure. Agree in advance on a stop signal, and on how the patient will use functional diversion to bring arousal down.
• Example language (illustrative): "You've chosen to let the sadness come for a few minutes without leaving it. I'll stay right here. Notice what your body does, and notice whether what you feared actually happens."
• Watch for: signs it is working include feelings described as painful but not dangerous, more tolerance, spontaneous self-exposure, and less instability. Signs it is not: dissociation or shutting down during the exercise, which is avoidance, not exposure. Lower the intensity.

4.16 Functional diversion

• Purpose: A deliberately chosen way to redirect attention from pain. It is used alongside graded exposure so the patient controls the dose and keeps daily life going. [source: Heggdal 2012 §8, glossary; Heggdal & Svergja v1.1; Hammer & Heggdal 2011]
• Steps: (1) Agree on non-destructive diversion activities with the patient. (2) Between exposure sessions, the patient chooses to use them to lower the intensity. (3) Staff help with the diversion if asked. (4) Talk about the choice openly: diversion is chosen, not automatic.
• Example language (illustrative): "You've stayed with it a long time. If you choose to take a walk now to let it settle, that's a choice you're making, and that counts."
• Watch for: diversion slipping into automatic, total avoidance, or the opposite, being forbidden as "avoidance". Keep the balance.

4.17 Flooding (full exposure)

• Purpose: Optional top of the hierarchy. The patient chooses to let themselves be fully overwhelmed by what they fear. [source: Heggdal 2012 §8 Phase 4; Heggdal, Fosse & Hammer 2016; Heggdal & Svergja v1.1]
• Steps:
  1. Use only when "the time is right": after graded exposure and with a stable alliance.
  2. Only at the patient's explicit choice.
  3. The therapist does not reduce the affect but stays present and validates throughout.
  4. Afterwards, review what the patient feared and what happened.
  Duration, setting and who is present are not described [uncertain].
• Safety [synthesis]: Get written or recorded consent for each flooding trial. Have medical cover available. Do not flood during psychosis, fragmentation or acute suicidal crisis. Plan aftercare for the following hours, because a failed or interrupted trial can strengthen the catastrophe belief.
• Example language (illustrative): "You've decided to let it all come this time. I won't try to stop it or make it smaller. I'll stay, and I'll tell you what I see."
• Watch for: the 2016 paper reports that patients with high exposure ratings (2–3) improved most. Watch for dissociation and post-session self-harm.

4.18 Solution-focused consolidation and self-exposure

• Purpose: Phase 5. Help the patient keep exposing themselves outside the therapeutic context and without the secure base, so that change generalises and self-efficacy grows. [source: Heggdal 2012 §8 Phase 5; Heggdal & Svergja v1.1]
• Steps:
  1. Identify concrete self-exposure patterns.
  2. Link them to the patient's better symptoms and functioning.
  3. Read automatic self-exposure as a sign that self-regulation is improving.
  4. Give the patient full credit.
  5. Wind the alliance down gradually and plan discharge.
• Example language (illustrative): "At home this weekend you let the anger come and didn't need to call anyone. That was you, not us."
• Watch for: relapse around discharge. Plan step-down follow-up [synthesis].

4.19 Collaborative medication review and reduction

• Purpose: Medication is treated as secondary to psychotherapy. Reduce it as the patient improves, in line with what the patient wants. [source: Hammer et al. 2018; Heggdal, Fosse & Hammer 2016]
• Steps:
  1. Start the discussion at the assessment interview.
  2. The doctor reviews effects, side effects, polypharmacy, dependence and the indication for each drug.
  3. Tie the decision to the patient's own values.
  4. Taper one drug at a time, as decided jointly by doctor and patient, avoiding compensatory medication where possible.
  5. The doctor attends all planning forums and the team reviews medication lists weekly.
  6. If tapering is not finished, discharge the patient with a written tapering plan for the follow-up service.
  No rates or doses are given here.
• Watch for: withdrawal symptoms, which were a reason some patients resisted tapering [source: Hammer et al. 2018]. Withdrawal can look like relapse. A prescriber must monitor it [synthesis].

4.20 Work with relatives

• Purpose: Reduce family patterns that keep the problems going. [source: Heggdal, Fosse & Hammer 2016]
• Steps: Usually 2–3 sessions with close relatives. The content is not published [uncertain]. [synthesis] Explain the model, especially why staff validate rather than rescue, and agree on how relatives will respond to crises after discharge.
• Watch for: relatives being told to withdraw warmth. Kjus (2021) describes services being told not to show care. Stress validation together with warmth [synthesis].

4.21 Coordination with GP, outpatient therapist and municipal services

• Purpose: Support autonomy after discharge. [source: Heggdal, Fosse & Hammer 2016]
• Steps [synthesis]: Hold handover meetings and share the patient's own self-exposure strategies, the tapering plan and the safety plan. The patient takes part.
• Watch for: the label "BET patient" making later help harder to get, and follow-up services copying a withholding stance (Kjus 2021). Hand over a clear crisis pathway [synthesis].

4.22 Multidisciplinary coordination and splitting management (staff-level)

• Purpose: Keep a steady, shared course around the clock. [source: Heggdal 2012 §7; Hammer & Heggdal 2011; Heggdal & Svergja v1.1]
• Steps:
  1. Evaluate often. Define who does what, when, where and how, and spread exposure tasks according to each member's skills.
  2. Accept the roles the patient assigns. Give explicit support to staff who are idealised or devalued, and reflect on those roles.
  3. Take over-regulation decisions as a team. Every member gives input, then everyone carries the decision out loyally.
  4. Name counter-transference in supervision.
  5. Use reflecting teams at patient and system level.
  6. Train staff through theory, workshops, feedback-based peer supervision, and the ACT Matrix (Polk & Schoendorff) to practise psychological flexibility.
  7. Hold frequent, intensive supervision where objections and critical questions are allowed.
  8. The implementation manual describes graded responses to staff departing from the model, from a light comment in a team meeting, to clarifying talks, to management review.
• Watch for: a team culture where dissent equals disloyalty. Supervision should also cover authenticity, not only adherence [source: Mjøsund et al. 2022 recommendation].

4.23 Therapist rotation

• Purpose: Vary the context so learning generalises and the process does not become static. [source: Heggdal, Fosse & Hammer 2016]
• Steps: Daily individual therapy rotates among the team's therapists.
• Watch for: rotation getting in the way of trust and shared goals (Mjøsund et al. 2022). Decide on rotation for each patient [source: Mjøsund et al. 2022 recommendation].

4.24 Attachment-strategy (DMM) assessment to tailor CER

• Purpose: Predict regression and tailor CER to the patient's attachment strategy. [source: Heggdal, Fosse & Hammer 2016; Heggdal IASA 2018 slides]
• Steps:
  1. Four team members independently rank the strategies they observe in the patient (3 = most prominent, 1 = rarely seen).
  2. They combine these into a consensus placement on a 1–8 scale running from A through A/C to C.
  How this placement changes the intervention is not described [uncertain].
• Watch for: ratings that confirm assumptions the team already holds.

4.25 Patient participation in treatment and team meetings

• Purpose: Give the patient ownership and transparency. [source: Heggdal, Fosse & Hammer 2016]
• Steps [synthesis]: Invite the patient to their own team meetings. Use a reflecting-team format where staff think aloud in front of the patient, then the patient responds.
• Watch for: the patient experiencing the meeting as judgment rather than collaboration.

5. Handling problems

Where a source covers the problem it is cited; everything else is marked [synthesis].

5.1 Stuck: no progression

• Sources: The manual's answer is time and choice. Each avoidance in a suitable situation delays change. The alliance is rebuilt as often as needed. After repeated regression, the team may use over-regulation until the patient takes initiative. [source: Heggdal 2012 §4.3, §8]
• [synthesis] Check the level of functioning (4.11); the challenge may be pitched too high. Ask for structured feedback from the patient, for example a session-by-session alliance or outcome measure. Mjøsund et al. (2022) recommend systematic feedback during treatment and noticing deterioration early.
• [synthesis] Set a review date. If there is no progress, or the patient is getting worse, change strategy, end BET or refer on rather than escalating over-regulation.

5.2 Resistance and ambivalence

• Sources: Accept them; do not treat them as disruptions. Validate the need for avoidance. Present choices, not truths. [source: Heggdal 2012 §8 Phases 2–3]
• [synthesis] Separate ambivalence about exposure from objections to the model itself, and take the latter seriously. Former patients felt their objections were automatically read as avoidance (Mjøsund et al. 2022).

5.3 Overwhelm, dissociation, fragmentation

• Sources: At the fragmentation or psychosis level, validate the fear of chaos, reduce stimulation, be clear and predictable, and use general external regulation. During graded exposure, use functional diversion to bring arousal down. [source: Heggdal 2012 §6, §8]
• [synthesis] Stop exposure and use grounding through functional diversion. Do not try flooding until the patient has been stable for some time. Review what the patient learned so the episode does not confirm the catastrophe belief.

5.4 Non-adherence (missed appointments, an ignored weekly plan)

• Sources: Under-regulation expects accountability: keeping appointments and telling staff about changes. The response is validation plus solution-focused questioning, not sanctions. [source: Heggdal, Fosse & Hammer 2016; Heggdal 2012 §4.1]
• [synthesis] Ask what the missed task would have exposed the patient to. Agree on a smaller next step.

5.5 Ruptures, splitting, idealisation and devaluation

• Sources: Accept the assigned roles. Support the staff member who is idealised or devalued. Reflect on roles in the team. Expect splitting as a developmental phase and validate both sides. [source: Heggdal 2012 §6–7]
• [synthesis] Repair ruptures openly: name your part in it, validate, and do not defend the model. Patients described staff as instrumental, cold and condescending (Mjøsund et al. 2022). Treat that feedback as a rupture to repair, not as splitting.

5.6 Self-harm, suicidal threats and suicide risk

• Sources: BET frames suicide as an ultimate attempt to escape basal phobia [source: Heggdal, Fosse & Hammer 2016]. Its stance on this is:
  • Threats are met with validation rather than detailed risk questioning [source: Hammer & Heggdal 2011].
  • Acute danger is managed with instrumental regulation, without exploring causes during the incident [source: Heggdal 2012 §4.2].
  • Repeated danger leads to over-regulation [source: Heggdal 2012 §4.3].
  • The 2016 paper describes no formal risk tool or safety plan [source: Heggdal, Fosse & Hammer 2016].
• Documented risk: Former patients describe staff not stepping in during serious self-harm and peers in danger, which they called "russian roulette" (Mjøsund et al. 2022). Kjus (2021) describes suicidal patients being left alone so they would "take responsibility". The BET section replied that such practice is incompatible with the model (Heggdal, Strand & Lilleby 2021).
• [synthesis] Integrate current standard practice. This is not optional:
  1. Do a structured suicide risk assessment at intake, at every change of CER mode, after any self-harm, and before leave or discharge.
  2. Keep a written, collaborative safety plan, including lethal-means counselling on storing and removing means.
  3. After any incident, the responsible clinician reviews risk with the patient once medical care is over. Validation does not replace this conversation.
  4. Never use under-regulation to justify leaving a patient at imminent risk unobserved.
  5. Document reasoning and follow the jurisdiction's mental-health law and incident-reporting duties.

5.7 Experience of coldness, abandonment or coercive choice

• Sources: Some patients experienced the treatment as harmful and coercive, and some got worse, with more shame, self-hatred, loneliness and reluctance to seek help again. [source: Mjøsund et al. 2022; Kjus 2021]. The BET team acknowledges that "BET er ikke løsningen for alle" (BET is not the solution for everyone) and says negative experiences must be taken seriously [source: Heggdal, Strand & Lilleby 2021].
• [synthesis] Ask regularly and in specific terms how the patient experiences staff warmth and safety. Offer a real exit to other care without penalty. Never present BET as a last chance.

5.8 Patient wants to talk about trauma or history

• Sources: In Mjøsund et al. (2022), participants found discussion of past trauma restricted and felt understood only through a narrow BET lens, and some felt re-traumatised. The authors recommend giving room for patients' own history.
• [synthesis] Allow room for history and trauma-informed formulation alongside the avoidance focus. For PTSD presentations, consider referral to a trauma-focused treatment.

5.9 Expectation mismatch at admission

• Sources: Expectations built on one-sided, unnuanced positive information did not match patients' actual experience (Mjøsund et al. 2022). [source]
• [synthesis] Use the balanced information steps in 4.1 and check expectations again at the end of week 1.

5.10 Over-regulation drifting into punishment or undocumented restriction

• [synthesis] Set a review interval. Keep empathic contact visible. Check the legal basis under local mental-health law. Record the patient's own words when they start a coping-dialogue, and step down promptly.

5.11 Medication withdrawal mistaken for relapse

• Sources: Withdrawal symptoms were a reason some patients resisted tapering [source: Hammer et al. 2018].
• [synthesis] The prescriber monitors withdrawal. Slow or pause tapering at the patient's request, and do not read a request to pause as avoidance.

5.12 Staff burnout, counter-transference, rigid model loyalty

• Sources: Staff can find BET hard. They must tolerate the patient's pain, and counter-transference can disturb treatment. The remedy is frequent supervision where criticism is allowed [source: Hammer & Heggdal 2011; Heggdal 2012 §7.3]. Mjøsund et al. (2022) also recommend collegial supervision focused on authenticity.
• [synthesis] Rotate demanding roles. Debrief after incidents. Guard against using sanctions on staff to shut down dissent.

5.13 Discharge, follow-up and the "BET patient" label

• Sources: Kjus (2021) reports being discharged while in an acute state, follow-up services told to be impersonal, and stigma that made later help harder to get.
• [synthesis] Discharge only with a stable safety plan and a named follow-up clinician. Brief receiving services to combine validation with warmth. Leave the label out of referral letters and describe the patient's own strategies instead.

5.14 Adapting BET outside an inpatient unit

• [synthesis] No published outpatient manual was found; Vestre Viken was looking into outpatient or outreach BET in 2024 [source: Helse Sør-Øst 2024]. An outpatient therapist can adapt validation (4.4–4.5), avoidance mapping (4.14), graded exposure and functional diversion (4.15–4.16), and solution-focused consolidation (4.18). Do not use over-regulation or flooding without a ward team, medical cover and legal framework, and do not call the work BET.

Sources

Sources

• BET principles and guidelines (Heggdal, Treatment Manual 1, v2.0, 2012)
• BET Implementeringsmanual v1.1 (Heggdal & Svergja) (only partly read)
• Heggdal, Fosse & Hammer (2016). Basal Exposure Therapy: A New Approach for Treatment-Resistant Patients with Severe and Composite Mental Disorders. Front. Psychiatry 7:198
• Hammer, Heggdal, Lillelien, Lilleby & Fosse (2018). Medisinfri etter basal eksponeringsterapi. Tidsskr Nor Legeforen
• Hammer & Heggdal (2011). BET – Basal Eksponeringsterapi. Psykisk helse og rus 3:12–17 (via Sykepleien)
• Heggdal, IASA 2018 conference slides
• Reduksjon av unngåelsesatferd og innleggelser grunnet villet egenskade etter BET (Suicidologi) (abstract only)
• Kjus (2021). En behandlingsform som påførte meg lidelse. Psykologtidsskriftet
• Heggdal, Strand & Lilleby (2021). Ikke forenelig med behandlingsmodellen. Psykologtidsskriftet
• Mjøsund, Strand, Nesset, Røysland-Sundhagen & Fosse (2022). Når behandling gjør vondt verre. Psykologtidsskriftet
• Internasjonal anerkjennelse for behandling uten tvang (Psykologtidsskriftet, 2021)
• Helse Sør-Øst, notat til HOD om BET (4 Jul 2024)
• Vestre Viken Brukerutvalg, foreløpig protokoll 10 Sep 2024

Further reading (not drawn on)

• Heggdal, D. (2008). Basal eksponeringsterapi: Grunnleggende prinsipper og retningslinjer (Norwegian treatment manual). Not drawn on [uncertain].
• Polk, K. L. & Schoendorff, B. (eds.) (2014). The ACT Matrix. Cited by the implementation manual.