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Basal Exposure Therapy (BET) combined with Complementary External Control (CER) – Norway

Basal Exposure Therapy (BET) and Complementary External Regulation (CER) are Norwegian practices with a strong psychotherapeutic focus that are designed for people who do not find success with conventional treatments. BET involves a hospital ward where people are given ‘an opportunity to expose themselves to their innermost fears in a safe, secure environment, rather than perpetuating and exacerbating phobic conditions through the continued excessive use of avoidant coping strategies’ (Submission 17C). The practice is premised on the idea that symptoms of severe, complex mental health challenges may originate from an impending or pervasive fear response, which the person is unable to address. The condition reportedly ‘manifests as a fear of disintegrating, of being engulfed by a total void or of being trapped forever in eternal pain’ in what is described as an ‘existential catastrophe anxiety’ (Submission 17C) (see Heggdal, 2012).

Service users/patients are never treated without consent. However, some individuals are detained in the hospital ward under civil commitment legislation. In such cases, ‘the aim of BET is to establish a working alliance with the service user, and on that basis terminate’ involuntary status and proceed with the therapy with the person’s informed consent (Submission 17C). The CER practice that occurs alongside BET, and which is discussed below, is designed explicitly to ‘eliminate coercive measures from the care process’ (Submission 17C).

A person can be admitted for BET inpatient treatment, if they have extensive prior treatment without notable and lasting effect, as well as ‘severe psychosocial dysfunction.’ There are six beds, and all service users have single bedroom. Inpatient care at the BET ward has a mean total duration of 3 months with a range of 1-4 months. However, length of inpatient stay is flexible and adapted to the needs of individual service users and based on practical circumstances. Normally, the treatment is offered within two stays. First, a short stay for approximately four weeks with emphasis on working-alliance and psychoeducation, and then a longer stay for 2-3 months working within the BET modality towards exposure.

Reportedly, there is ‘in practice, no use of restraint measures’ (Submission 17C). ‘Shielding’, defined as the confinement of patients to a single room or a separate unit/area inside the ward, accompanied by a member of staff, has been used on two occasions ‘to protect life and health’ between March 2018 and December 2020.

The primary intervention in BET is psychosocial and ‘medication is auxiliary, or subservient to the therapeutic process’ (Submission 17C). Service users are given the opportunity to taper from their medications. The rationale for tapering is that medications can ‘prevent the person from accessing their inner experiences, and thereby also obstruct his or her opportunity to make use of exposure therapy’ (Submission 17C) (see Hammer, Heggdal, Lillelien, Lilleby, & Fosse, 2018). During the weeks or months prior to admission, the BET team often initiates a dialogue about tapering medications with the informed consent of the service user (Hammer et al., 2018). Tapering or discontinuation is generally done very slowly, one drug at a time. The timeline and chronology are usually decided during a dialogue aimed at promoting autonomy and user participation. Some service users do not wish to taper their use of drugs.

CER is an approach initiated as soon as the person enters the 24/7 BET service. CER aims to facilitate and consolidate positive functional choices and actions, and to eliminate coercive measures from the care process (Heggdal, 2012). CER’s primary strategy is ‘under-regulation’; therapists interact with service users in a non-hierarchical manner, treating them as equals who are fully responsible for their own choices and actions (Heggdal, 2012). For example, the people admitted to the BET unit are free to leave the ward whenever they want (unless, on rare occasions, a person is detained involuntarily, as noted above). At the same time, they are held accountable for being on time for appointments (Heggdal et al., 2016). The BET team never reminds or tells people to take their medications or eat their meals. At all times, there is acknowledgment and recognition that the people using the services are capable of making their own decisions. They are, however, encouraged to notify staff members when they leave the unit and to be transparent about any plans they may have to leave.

If a service user harms him or herself while on the ward, the BET team will not impose any restrictive measures. Instead, follow-up will focus exclusively on providing the medical attention the person requires after the self-harm event (for example, getting stitches for any wounds). After addressing the person’s medical needs, the under-regulated approach is continued.

Over the past two years, there has been only one occasion when the safety and well-being of other service users or therapists were threatened at the BET unit. Good communication and verbal de-escalation are used to address conflict, and the person may be asked to leave the unit or to consider referral to another unit. At the BET unit, service users are invited to ‘take ownership of their problems as the starting point for a dialogue with BET therapists to address the challenges they face’ (Submission 17C).

In situations in which a service user’s actions present an acute threat to life and/or health, and no efforts are made to initiate or maintain dialogue, the service team, together with the service user, may agree on a strategy to introduce an ‘over-regulation’ phase. Over-regulation is a coordinated approach whereby the service user is under-stimulated, i.e., everything is slowed down (Heggdal, 2012). Therapists speak slowly and pause for longer than usual before responding, and the service user is met in ways that ‘do not support and maintain dysfunctional behavior and marginalizing interactions’ (Submission 17C). By creating a low-stimulation environment, the aim of ‘over-regulation’ is to ‘allow the service user to experience a situation without any of the dependency associated with being ‘regulated’ by health care workers’ and attention is given to ensuring therapists are available when a person wishes to initiate dialogue to hear what the user thinks and suggests (Hammer, Fosse, Lyngstad, Møller, & Heggdal, 2016; Heggdal, 2012; Heggdal et al., 2016).

In principle, staff may alternate between under-regulation and over-regulation to support the service users and facilitate progress and improvement. However, over-regulation is ‘very rarely used by the service’ (Submission 17C). Since the start of the development of the CER strategy in 2006 it has been necessary to deploy this ‘control element’ on ‘no more than four or five occasions’. In each case, the service user’s life and health were at risk in acute situations, and the BET team had to take over some control to ‘prevent the person from taking his/her own life or inflicting severe, irreversible physical injury’. However, ‘well-coordinated under-regulation is the primary means used by the service to address suicidal and self-harming actions’ (Submission 17C).

The successful application of the CER strategy reportedly ‘secures and strengthens the person’s autonomy, ensuring that the inpatient stay can be used to address mental health challenges rather than dealing with acute crises’ (Submission 17C) (See also Heggdal et al., 2016).