Dialogical exposure therapy

1. Introduction

Version followed: Butollo & Karl (2012), Dialogische Traumatherapie: Manual zur Behandlung der Posttraumatischen Belastungsstörung (Klett-Cotta, Leben Lernen 256). This is the manual used in the LMU Munich trials (pilot 2014, RCT 2016). Unverified warning. The manual's publicly available parts are the publisher's reading sample (front matter, full table of contents, Vorwort, Prolog and the start of Chapter 1); the trials are drawn on through their published abstracts and records. No public source outside the manual (trial abstracts and records, the trial dissertation, German training pages) describes its procedures step by step [uncertain]. Verified: the RCT design (141 adult outpatients with PTSD after Type I trauma in adulthood; DET as an integrative, gestalt-derived treatment; flexible length up to 24 sessions; CPT as comparison); that DET is gestalt-based with CBT elements (König 2012); and that a separate controlled trial used dialogical exposure with traumatically bereaved Bosnian women (Hagl et al. 2015). Still unverified, so marked [synthesis] or [uncertain]: the manual's step-by-step procedures, exclusion criteria, session length and frequency, criteria for moving between phases and for ending, and its responses to the four difficulties it names. Structure and names in this guide come from the manual's table of contents. Step-by-step detail is the writer's synthesis and is labelled [synthesis].

What it is. Dialogical exposure therapy (DET; German: Dialogische Traumatherapie / Dialogische Exposition) is an outpatient PTSD treatment developed by Willi Butollo and colleagues (Regina Karl, Julia König, Rita Rosner, Maria Hagl) at the psychotherapy and trauma outpatient clinic of LMU Munich. The authors call it a process-oriented, integrative treatment: a Gestalt-therapy frame with cognitive-behavioural elements, committed to an interactional, dialogical approach [source: Butollo et al. 2014, Gestalt Review abstract; Butollo & Karl 2012, Vorwort]. In the RCT it was described as "an integrative gestalt-derived intervention" and delivered flexibly, up to 24 sessions, to adult outpatients with PTSD after Type I trauma in adulthood [source: Butollo et al. 2016 abstract]. The manual calls itself a set of explained working heuristics (Arbeitsheuristiken), not a rigid protocol, and is loosely ordered into four phases [source: Butollo & Karl 2012, Vorwort].

How change happens (authors' model). Trauma is understood mainly as a disturbance of self-processes. Those processes form through contact, the boundary between "I" and "not-I". During the trauma the person experiences powerlessness in relation to a counterpart: a perpetrator, but also a wave, an earthquake or an aggressive driver. That relationship is internalised as a pattern that reminders reactivate. The person then meets the world as a helpless victim (a "trauma self"), and a submission reflex that once helped survival becomes a lasting pattern. Change comes from restoring the capacity for contact and dialogue. The therapist works with the real therapy relationship and with internalised relationships, including the internal representation of the aggressor (Aggressorrepräsentanz), approached gradually through dialogue and role-play. The intended result is that the self regains its capacity to act and express itself, and that the patient again experiences continuity in their experience [source: Butollo & Karl 2012, Ch. 1 and Prolog; Butollo et al. 2014, Gestalt Review abstract]. The authors trace dialogical exposure to Jacob Moreno (psychodrama) and Fritz Perls (Gestalt), adapted for traumatised people [source: Butollo & Karl 2012, Prolog].

2. Framework

Setting and dose. Individual outpatient therapy. In the RCT (141 adult outpatients) the length was flexible, with a maximum of 24 sessions [source: Butollo et al. 2016 abstract; KU.edoc record]. In the pilot, 25 outpatients started and 21 completed [source: Butollo et al. 2014, Psychotherapy Research]. Dialogical exposure was also tested in a controlled trial with traumatically bereaved Bosnian women (Hagl, Powell, Rosner & Butollo 2015). Only the bibliographic record of that trial is drawn on, so its format and dose are unknown [uncertain]. Session length and frequency are not given in the RCT record, the trial registration or the trial dissertation [uncertain]. Weekly sessions of about 50 minutes, with longer slots for Phase III dialogical exposure, are a reasonable default [synthesis]. The trials tested adults with Type I trauma (a single event) in adulthood. The authors say the model applies to both Type I and Type II trauma, especially Type II, and that the clinic also uses it with complex traumatic stress outside the trial design [source: Butollo & Karl 2012, Ch. 1, Vorwort]. With complex or childhood trauma, expect a longer course and a longer Phase I–II [synthesis].

Overall arc. The work runs from highly structured, behavioural symptom reduction towards humanistic principles: awareness, resource orientation, self-acceptance and responsibility [source: Butollo & Karl 2012, Vorwort]. Chapter 1 gives the intended order:

1. Find where the trauma self is reactivated in daily life.
2. Trace the processes that weaken the self, and the beliefs behind them.
3. Build alternative skills.
4. Adjust current relationships.
5. Only then, and only if the patient wishes, bring the original traumatic relationship into the session as role-play.

[source: Butollo & Karl 2012, Ch. 1]

Three running foci (all phases): (1) handling symptoms, with attention to their interactional side and to disturbances of the self; (2) activating resources, especially pre-traumatic, self-strengthening relationship experiences; (3) shaping contact and relationships, including social-skills practice and gradual role-play approach to the traumatic relationship. A fourth aim, self-acceptance, runs through all of them [source: Butollo & Karl 2012, Ch. 1; TOC Ch. 4].

Treatment start (manual Ch. 3). Start of trauma therapy; inclusion and exclusion criteria; therapist behaviour; session sequence and division; and "telling the traumatic experience – narrative confrontation" [source: TOC Ch. 3]. Diagnosis covers PTSD criteria, course and comorbidity [source: TOC Ch. 2]. The trials enrolled adult outpatients with PTSD after a single (Type I) trauma in adulthood [source: Butollo et al. 2016 abstract; KU.edoc record]. The trials' exclusion criteria and these manual sections are not drawn on [uncertain].

[source: phases and goals from Butollo & Karl 2012, TOC Ch. 5–9, 11–12]. The manual calls the phase order "loose" [source: Vorwort]. Explicit transition criteria (Ch. 5 "Aufbau der Therapie") are not published outside the manual, so the right-hand column is the writer's synthesis [synthesis].

3. Guiding principles

[source for each: Butollo & Karl 2012, Vorwort, Prolog, Ch. 1 unless marked]

• Trauma is a disturbance of contact and self-processes, not only a symptom cluster. In practice: assess how the patient now meets other people and the world (withdrawal, barrier, submission), not just PTSD symptoms.
• Trauma therapy is primarily relationship therapy. In practice: name and work with what happens between you and the patient in the session. The manual says it makes the therapist–patient relationship explicit.
• The overarching goal is restoring the capacity for contact and dialogue, and trust in the world and in others. In practice: count it as progress when the patient can be in real dialogue again, even if symptom scores fall only modestly. The authors hold that therapy is worthwhile in that case.
• Symptoms are protective achievements. In practice: acknowledge what a symptom (numbing, avoidance, distance) protects before working to reduce it. Treating symptoms only as faults widens the split between the vulnerable self and the "norm-conforming" self.
• Do not shrink the event. In practice: acknowledge the full weight of what happened and of the loss. Taking away its weight would diminish the person's dignity.
• Guard against compliance. In practice: patients may report improvement to please the therapist or to avoid being excluded. Invite disagreement and support the patient in defending how they are now.
• Self-acceptance and responsibility. In practice: help the patient accept their current state rather than fight it, and own their choices from here on.
• Resource orientation, especially pre-traumatic relationships. In practice: actively bring back earlier experiences of being supported, competent and connected, and current supportive people.
• Gradual approach, patient's choice. In practice: work on current daily-life triggers and current relationships before the original trauma. Bring the traumatic relationship into role-play only once the patient wants to.
• Approach rather than distance. In practice: where a patient is stuck halfway between holding on and keeping away (for example from the dead, or from the aggressor), invite direct contact in dialogue form rather than "letting go" [source: Prolog].
• The psyche always builds an interaction partner. In practice: any counterpart (a person, an animal, nature, the sea, the earth) can be addressed in dialogue, including the non-human forces of accidents and disasters.
• Working heuristics, not a rigid protocol. In practice: adapt the order and the dose to the patient. The four phases are a loose map.
• Awareness (Gestalt). In practice: keep attention on present experience in the body, the emotions and the contact as material for change [source: Vorwort; TOC 10.2.1].
• Dialogical stance (Dialogische Haltung, manual 2.3) and therapist behaviour (3.3). The content is not published outside the manual [uncertain]. The public parts of the manual do not mention Buber's I–Thou, so do not attribute it to the authors [uncertain].

4. Intervention inventory

How to read this section. Every intervention named below is listed in the manual's table of contents (section number given) or described in the Prolog. The existence and placement of each is therefore sourced [source: Butollo & Karl 2012, TOC]. Apart from the Prolog case and the Chapter 1 principles, the content of those chapters is not publicly available. So unless a step carries a [source] tag, the steps, wording and watch-points are the writer's synthesis from general Gestalt/CBT trauma practice, built to fit the authors' stated model [synthesis]. Check them against the manual (Chapters 6–9 and 14) before relying on them as "DET as published". All example language is illustrative.

4.1 Start of therapy and assessment (manual 2.1.5, 3.1–3.3)

• Purpose: Confirm PTSD and comorbidity, check whether trauma therapy is indicated, and establish the working relationship and its explicit, dialogical character [source: TOC].
• Steps: [synthesis] (1) Before anything else, acknowledge the weight of what happened. The authors' therapist opened by referring to what the client had written and saying how sorry he was that the client had to bear it [source: Prolog]. (2) Ask how the person is now and what brings them, and listen for contact symptoms (barrier to the world, no energy, "nothing matters") as well as intrusions, avoidance, sleep problems, guilt and death wishes [source: Prolog]. (3) Run a structured PTSD assessment with a validated instrument, and screen for suicidality, dissociation, substance use, psychosis and current danger. (4) Map current relationships and pre-traumatic resources. (5) Agree goals across the three foci (symptoms, resources, contact) and explain the loose four-phase plan and the patient's control over any confrontation.
• Exclusion criteria: the content of manual 3.2 is not published outside the manual [uncertain]. Treat these as contraindications to confrontation work until resolved: ongoing contact with the perpetrator where re-traumatisation is possible, acute suicidality, acute psychosis. Treat these as relative contraindications needing longer stabilisation: poor affect tolerance, severe dissociation, uncontrolled self-harm, heavy current stress [source: Müller, reading sample, secondary German trauma-confrontation text; synthesis].
• Example language (illustrative): "What happened to you is beyond what anyone should have to carry. I don't want to make it smaller than it is. Can you tell me how you are doing these days, and what made you come now?"
• Watch for: Flat, detached reporting (protective numbing; note it, don't push). Pleasing the therapist. Death wishes that need a full risk assessment.

4.2 Narrative confrontation: telling the traumatic experience (manual 3.5)

• Purpose: Get a first account of the event, see how the patient relates to it (flat, flooded, avoidant) and find the relational core [source: TOC 3.5; Prolog].
• Steps: (1) Ask the patient to describe what happened, at their own pace [source: Prolog]. (2) [synthesis] Let them set the depth. This is not yet full exposure, so do not ask for every sensory detail. (3) Notice what is missing. In the Prolog the therapist noticed that the good memories of the lost people had gone too and asked about the good times before; grief then surfaced [source: Prolog]. (4) [synthesis] Close by checking present-moment orientation and current distress.
• Example language (illustrative): "Would you tell me what happened, as much as feels right today? You can stop at any point." / "I notice you describe it very calmly, almost from far away. And it seems the good memories of her have gone quiet as well."
• Watch for: Rising arousal or dissociation (slow down, ground: see 5.4). A relieved shift towards emotion, which signals contact.

4.3 Symptom-oriented work (Focus 1; manual 4.1, 10.1)

• Purpose: Structured, behavioural reduction of PTSD symptoms that also attends to their interactional side and their protective function [source: Vorwort; Ch. 1; TOC 4.1, 10.1].
• Steps: [synthesis] (1) Give psychoeducation on PTSD and on symptoms as protection. (2) For each main symptom, map trigger, response and what it protects. (3) Agree a practical coping plan (see sleep hygiene, rumination, anxiety psychoeducation, 4.27–4.29). (4) Ask what the symptom does in relationships (for example, irritability that keeps people away).
• Example language (illustrative): "This numbness kept you going. It also keeps people out. Let's look at both sides."
• Watch for: Pressure to "get rid of" symptoms quickly, from the patient or from you.

Phase I – Safety (manual Ch. 6)

4.4 Activating and differentiating safety (6.1)

• Purpose: Re-establish a felt sense of safety and tell apart what is actually dangerous now from what only feels dangerous because of the trauma [source: TOC 6.1].
• Steps: [synthesis] (1) List the safety aspects: physical (home, route, body), social (people), internal (skills, beliefs). (2) Rate each now versus before the trauma. (3) Separate realistic present risks, which need practical action, from trauma-generalised alarm, which needs work on the internal relationship. (4) Pick one realistic safety step for the week.
• Example language (illustrative): "Which places and people feel safe right now, even a little? And where does your body raise the alarm even though you know nothing is happening there now?"
• Watch for: Real ongoing danger (deal with it first). Global "nothing is safe" (start with micro-safety in the room).

4.5 Contact with safety-giving pre-traumatic self-parts and existing resources (6.2, 6.2.1)

• Purpose: Reconnect with the self from before the trauma (capable, connected) to counter the "trauma self" [source: TOC 6.2; Ch. 1 on reactivating pre-traumatic self-strengthening relationship experience].
• Steps: [synthesis] (1) Elicit concrete memories of competence, pleasure and being supported before the trauma. (2) Deepen one in the present tense with awareness of the body. (3) Optionally invite a short dialogue: the patient speaks to, or as, that earlier self. (4) Ask what that self would advise now. (5) Anchor it with a word, image or posture to use between sessions.
• Example language (illustrative): "Think of a time before all this when you felt sure of yourself. Where are you, what do you notice in your body? If that person could speak to you now, what would they say?"
• Watch for: Grief about what was lost can break in. Acknowledge it and come back to the resource, or note it for Phase IV.

4.6 Belonging: activating social resources and supportive relationships (6.2.2)

• Purpose: Restore the experience of belonging and support, against post-traumatic withdrawal and mistrust [source: TOC 6.2.2; Ch. 1].
• Steps: [synthesis] (1) Draw a relationship map: who is close, who has drifted away, who supports. (2) Explore what makes contact hard now (shame, feeling different, others' reactions). (3) Plan one small contact step. (4) Rehearse it in role-play if needed (see 4.12).
• Example language (illustrative): "Who would you want to know a little more about how you are? What could a first, small message to them look like?"
• Watch for: Unsupportive or blaming networks (choose safer people). Over-reliance on the therapist as the only contact.

4.7 Work on intrusions (6.3)

• Purpose: Reduce the overwhelm of intrusive memories and nightmares and increase felt control [source: TOC 6.3].
• Steps: [synthesis] (1) Explain intrusions as unprocessed memory and an alarm that has not been switched off. (2) Map triggers. (3) Teach present-orientation and grounding: name the date, the place, five things you see, feet on the floor. (4) Teach distancing: notice that it is a memory, then turn attention to the present. (5) Keep an intrusion log. Do not process the content yet; that belongs in Phase III.
• Example language (illustrative): "When the picture comes, try saying to yourself: this is a memory, I am here in my kitchen, it is Tuesday. Then look for three things you can see."
• Watch for: Grounding used as permanent avoidance. Very frequent intrusions with dissociation (extend stabilisation).

4.8 Generating safety (6.4)

• Purpose: Build new, active sources of safety that the patient creates rather than only recovers [source: TOC 6.4].
• Steps: [synthesis] (1) Agree daily structure and self-care. (2) Develop a personal safety plan for crises (warning signs, actions, contacts). (3) Practise one safety skill in session until the patient can do it alone.
• Example language (illustrative): "What helps you feel a bit steadier at the end of a bad day? Let's turn that into a plan you can use."
• Watch for: The plan stays on paper. Ask about actual use next session.

Phase II – Inner stability, "self-safety" (manual Ch. 7)

4.9 Emotion work away from the centre of the traumatic experience (7.1)

• Purpose: Build tolerance and expression of emotion on less loaded material before touching the trauma core [source: TOC 7.1].
• Steps: [synthesis] (1) Choose a current situation with moderate emotion. (2) Bring awareness to body, feeling and impulse. (3) Name the emotion and its need. (4) Express it: in words to the therapist, or in an imagined dialogue with the person involved, an empty-chair style format. Chair work is not confirmed by name in the text [uncertain]. (5) Reflect on what changed.
• Example language (illustrative): "As you talk about your colleague, what happens in your chest? If he were sitting over there, what would you want to say to him?"
• Watch for: Sudden leaps to trauma content (slow down). Intellectualising (bring back to the body).

4.10 Work on specific emotions (7.2): traumatic fear, grief, guilt, shame, powerlessness/anger/rage/aggression, disgust

• Purpose: Each of these emotions is named in the manual as a separate work area [source: TOC 7.2.1–7.2.6].
• Steps: [synthesis] Traumatic fear: psychoeducation (see 4.29), separate then-fear from now-fear, and pair it with safety resources. Grief: acknowledge the losses (people, the old self, trust), give space to cry and to speak to the lost person (see 4.21). Guilt: separate responsibility from guilt, check hindsight bias (what could you know then?), and let the guilty part and an understanding part dialogue. Shame: name it, normalise it, explore whose gaze it is, and bring in self-compassion and contact with the therapist (shame lessens when it is met). Powerlessness/anger/rage/aggression: recognise anger as energy against submission, express it safely (voice, posture), and channel it into boundaries. Disgust: recognise it as a protective reaction, notice it in the body, and separate it from self-worth.
• Example language (illustrative): "Part of you says it was your fault. Let that part speak. Now, what would the part that knows what you could see in that moment answer?"
• Watch for: Shame is easily triggered by the therapist's own reactions, so track the contact. Anger work tipping into loss of control.

4.11 Inner dialogues: the role of cognitions (7.3)

• Purpose: The manual treats cognitions as inner dialogues. Identify the voices that weaken the self (for example, an accusing or belittling voice) and the beliefs behind them [source: TOC 7.3; Ch. 1].
• Steps: [synthesis] (1) Collect typical self-statements after triggers. (2) Give each a voice and position: whose voice is it, and how does it speak? (3) Let the patient answer from the self in the here and now. (4) Develop an alternative, self-supporting inner response and practise it.
• Example language (illustrative): "When you say 'I should have known,' whose voice is that? Say it out loud to yourself, then switch and answer it as you would answer a friend."
• Watch for: The patient arguing rationally without feeling (see 5.6). Collapse into the critic's position.

4.12 Self-perception and relationships; defending one's own needs with others (7.4, 7.5)

• Purpose: Help the patient perceive themselves accurately in relationships and defend their needs, against the submission pattern of the trauma self [source: TOC 7.4, 7.5; Ch. 1].
• Steps: [synthesis] (1) Find current situations where the patient gives in or withdraws. (2) Define the need and an appropriate statement. (3) Role-play it: the therapist plays the other person, then the roles switch. (4) Coach posture, voice and eye contact. (5) Set a real-life experiment and review it.
• Example language (illustrative): "Let's try it. I'm your manager, I've just given you the extra shift again. Tell me what you need, standing the way you'd like to stand."
• Watch for: Freezing in the role-play (reduce intensity). Unsafe real-life relationships where assertiveness carries risk.

Phase III – Confrontation (manual Ch. 8)

Readiness for Phase III [synthesis; the manual's criteria are not public, uncertain]. All of these should hold:

• The patient explicitly wants to approach the trauma; the authors make this conditional on the patient's wish [source: Ch. 1].
• There is no current perpetrator contact or acute risk.
• The patient can use grounding and come back from distress within a session.
• The patient can hold an inner dialogue in Phase II work without collapsing.
• There is enough support between sessions.

Get informed consent for the exposure work: what will happen, the likely temporary increase in distress, and the right to stop at any point [synthesis; the manual's consent procedure is not public, uncertain].

4.13 Object-oriented (situational) exposure with active control of imagery (8.1, 8.1.1)

• Purpose: Confront the traumatic situation in imagination while the patient keeps active control over the inner images. This is a first, situation-focused exposure step before the relational (dialogical) step [source: TOC 8.1, 8.1.1].
• Steps: [synthesis] (1) Pick the scene and agree a stop signal. (2) Take a baseline distress rating (0–100). (3) The patient brings up the scene with eyes open or closed and describes it in the present tense. (4) Teach and practise active control of the image: pause it, step it back, make it smaller or further away, change the viewing position, add a safe person or resource, then bring it closer again. Control, not maximum intensity, is the aim. (5) Repeat the passage until distress clearly falls or control feels secure. (6) Close with grounding and a final distress rating. Dose: one scene per session, with at least 15 minutes for closure.
• Example language (illustrative): "Let the picture come only as close as you can handle. Now try pausing it, like a film. Good. Can you move it a little further away? Notice that you are the one controlling it."
• Watch for: Dissociation (glazed look, flat voice, losing the present): stop, ground (see 5.4). Using image-control to never actually look (gently increase closeness over sessions).

4.14 Further themes of object-oriented confrontation (8.1.2)

• Purpose: The manual lists further themes here; their content is not published outside the manual [uncertain]. [synthesis] Apply the same controlled imaginal method to other loaded situations: hotspots, the moment of helplessness, the aftermath, and present-day reminders (in vivo, where safe).
• Steps / Example / Watch for: As 4.13.

4.15 Preparation for dialogical exposure (8.1.3)

• Purpose: Move from "situation" to "relationship": identify the counterpart of the trauma and prepare the patient to meet its internal representation [source: TOC 8.1.3; Ch. 1].
• Steps: [synthesis] (1) Identify the counterpart: the perpetrator, or for accidents and disasters the force or agent (the wave, the earthquake, the other driver), which the authors explicitly include [source: Ch. 1]. (2) Explore the relational pattern from the event: who was powerful, who was powerless, and the submission reflex. (3) Agree the format: where the representation is placed in the room (for example, a chair or cushion at a distance the patient chooses), who may move it, and the stop signal. (4) Rehearse a resourced position: posture, breathing, a supporter beside the patient. (5) Clarify the purpose: the patient is not meeting the real person, and the aim is to change their own relation to that inner figure, not to reconcile or forgive.
• Example language (illustrative): "In your mind that person still has a lot of power over you. We could give that inner image a place here in the room, as far away as you like, and you could find out what it is like to speak to it from where you are today. You decide whether, when and how far."
• Watch for: Ambivalence or compliance. Revisit consent and do not proceed on the therapist's agenda.

4.16 Dialogical exposure: interactional confrontation with the aggressor representation (8.2, 8.2.1)

• Purpose: The core DET method. In a role-play-based dialogue, the patient confronts the internalised representation of the aggressor, so that the trauma self's pattern of contact (powerlessness, submission, avoidance) can change and the capacity for contact returns [source: TOC 8.2; Ch. 1; Gestalt Review abstract]. The authors derive it from Moreno and Perls [source: Prolog]. The detailed procedure in the manual is not drawn on. The steps below are a synthesis consistent with that lineage and with the authors' model [synthesis].
• Steps: [synthesis]
  1. Check in: current distress, consent, stop signal.
  2. The patient places the aggressor representation (empty chair or object) at a chosen distance, then describes what they see: posture, look, expression.
  3. Track the bodily reaction (freeze, shrink, look away) and name it as the old pattern.
  4. Invite the patient to speak directly to the figure, beginning with what they notice now ("When I look at you, I…").
  5. Support each statement and slow the pace. Encourage first person, direct address and present tense.
  6. Strengthen the patient's position: stand up, sit taller, plant the feet, bring the voice up, place the therapist alongside as support.
  7. Let the patient say what they could not say then: what was done, its effect, what they think and feel about it, boundaries ("Stop", "No further").
  8. Take distress readings at transitions; adjust distance and intensity.
  9. End the dialogue with a closing statement and physically move or remove the figure.
  10. Leave the role, ground, and debrief: what was it like, what changed in your body or your sense of yourself?
• Dose and closure: [synthesis] One dialogue segment per session. Leave 15–20 minutes for de-roling, grounding and debriefing. Repeat across sessions until the patient can stay present and upright towards the figure.
• Example language (illustrative): "Look over there for a moment. What happens in you?… Tell him directly: 'When I see you, I…'. Take your time. Stay with your feet on the floor. I'm right here next to you."
• Watch for: Signs it is working: the patient's voice gets steadier, their posture straightens, they report "he seems smaller", spontaneous anger or grief comes and passes, and they say less "I couldn't" and more "you did". Risk signs: flooding, dissociation, self-blame taking over, freezing. Respond as in 5.4 and 5.7. Never use suggestion or hypnosis to "fill in" memories. Work with the patient's experience as they report it, not as facts to uncover [synthesis, Domain VI rule].

4.17 Dialogue between self and object representation (8.2.2)

• Purpose: Extend the confrontation into a two-sided dialogue between the self and the internal representation of the other [source: TOC 8.2.2].
• Steps: [synthesis; whether the manual uses role reversal is uncertain] (1) After the patient has spoken, ask what the figure would answer. (2) Optionally, and only if the patient is stable and willing, have them briefly take the figure's position in its chair to voice the internalised message, so it becomes visible as an inner voice. (3) Return them promptly to their own chair, de-role, and let them answer from the self. (4) Alternate until the self's position is stable.
• Example language (illustrative): "What does the figure in your head say back to you?… Come back to your own chair. Shake that off. Now, how do you answer that?"
• Watch for: Getting stuck in the aggressor role, or being re-traumatised by it. Keep it short, and always end in the self's position.

4.18 Confrontation with one's own aggressive parts (8.2.3)

• Purpose: Address the patient's own aggressive impulses: revenge fantasies, rage, perhaps aggression the patient used. These are often feared or shamed after trauma [source: TOC 8.2.3].
• Steps: [synthesis] (1) Name and normalise anger and revenge fantasies as reactions to powerlessness. (2) Give the aggressive part a voice in dialogue. (3) Separate impulse from action. (4) Find what it protects or needs. (5) Plan safe expression.
• Example language (illustrative): "There's a part of you that wants him to suffer too. Let it speak, here, safely. What does it want for you?"
• Watch for: Real risk of harm to others. Assess it and follow duty-to-protect rules.

4.19 Transfer into everyday life (8.3)

• Purpose: Carry the changed stance into current relationships and situations [source: TOC 8.3].
• Steps: [synthesis] (1) Find everyday situations where the old pattern shows (with authority figures, in conflict, in crowds). (2) Plan behavioural experiments. (3) Review them, and role-play again if needed.
• Example language (illustrative): "Where in your week might you meet a little of that old feeling of being small? What would you like to try there?"
• Watch for: Generalising gains to unsafe real people (in vivo confrontation with an actual perpetrator is not implied).

Phase IV – Integration (manual Ch. 9)

4.20 Accepting the traumatic experience, and with it the change (9.1)

• Purpose: Help the patient accept that the trauma happened and changed them, rather than fighting it or trying to restore the old self [source: TOC 9.1; Ch. 1 on self-acceptance].
• Steps: [synthesis] (1) Explore "before / after" selves. (2) Name what is irreversibly changed and what remains. (3) Use a dialogue between the part that wants it undone and the part that lives now. (4) Write a short integrating narrative.
• Example language (illustrative): "It happened, and it changed you. What would it be like to say that out loud, without adding 'but it shouldn't have'?"
• Watch for: Acceptance heard as condoning. Clarify the difference.

4.21 Grief and posttraumatic maturation (9.4), including dialogue with the lost person (Prolog)

• Purpose: Grieve the losses (people, trust, the former self) and allow growth. The Prolog shows the authors' way of working with traumatic bereavement [source: TOC 9.4; Prolog].
• Steps (Prolog case, paraphrased):
  1. Explore the bond. The client said he thought of his wife and daughter constantly but only "latently" and pushed the images away. The therapist reflected that the good memories had been lost as well and asked about the good times; grief emerged [source: Prolog].
  2. Ask whether there are things the patient still wants to say to them [source: Prolog].
  3. If the patient objects that it is too late or that she cannot hear, explain briefly: he is trying to distance himself from the dead and is stuck halfway, held back by guilt; the alternative is to bring them close and speak to them directly [source: Prolog, paraphrased].
  4. Invite the patient to imagine the person opposite and to speak directly to them, beginning with one person, with an inviting gesture [source: Prolog].
  5. Let the patient express what comes (in the case: loneliness, guilt, despair, longing), then say goodbye inwardly. Repeat with the other lost person [source: Prolog].
  6. [synthesis] Debrief and ground, and normalise strong emotion.
  The authors describe the outcome as a shift from fixation on the accident to an inner relationship with the dead, with relief, and note that many questions remained open [source: Prolog].
• Example language (illustrative): "Is there something you never got to say to her? … You could imagine her sitting here across from you, and tell her, directly, now."
• Watch for: Intense grief is expected and is not a sign of harm. Watch for flooding or suicidal ideation linked to reunion wishes (assess directly). Posttraumatic maturation is reflected, not prescribed.

4.22 Identifying isolated, alienated self-parts (9.2)

• Purpose: Find parts of the self split off since the trauma (for example the playful, trusting or vulnerable part) and bring them back into contact [source: TOC 9.2; Ch. 1 on the self "splitting"].
• Steps: [synthesis] (1) Ask what has been lost from the self. (2) Locate the part (image, age, body). (3) Hold a dialogue between the current self and that part. (4) Agree small ways to let it live again.
• Example language (illustrative): "Which part of you went quiet after it happened? If it could speak, what would it say about why it went away?"
• Watch for: Severe dissociative structure (if suspected, assess for a dissociative disorder and adapt treatment) [synthesis].

4.23 Integrating aggressive parts (9.3)

• Purpose: Turn the aggression worked with in 4.18 into usable self-assertion and vitality [source: TOC 9.3].
• Steps: [synthesis] (1) Review what the aggressive part has protected. (2) Hold a dialogue to give it a legitimate role (boundaries, energy). (3) Practise using it in everyday assertiveness.
• Example language (illustrative): "That fierce part kept you from giving up. Where could it help you set limits now?"
• Watch for: Lingering shame about aggression.

4.24 Desensitising emotions experienced as threatening (9.5)

• Purpose: Reduce fear of the emotions themselves (anger, grief, fear, joy) so that they no longer trigger avoidance [source: TOC 9.5].
• Steps: [synthesis] (1) Rank feared emotions. (2) Approach each gradually in session through awareness, expression and dialogue. (3) Stay until the emotion peaks and passes. (4) Practise allowing it between sessions.
• Example language (illustrative): "Let's let the sadness be here for a minute, without stopping it. I'll keep track of time. Notice what happens to it."
• Watch for: Flooding (shorten the steps). Using it to bypass unresolved trauma material.

Exercises used across phases (manual Ch. 10.2 and Ch. 14)

The manual groups its exercises under these headings [source: TOC 10.2, 14]. The specific exercises inside each group are not publicly available [uncertain], so the examples below are generic Gestalt/CBT exercises that fit each heading [synthesis].

4.25 Awareness: attention and perception exercises (10.2.1, 14.1)

• Purpose: Build present-moment contact with body, senses and surroundings. This is the Gestalt basis for every other step and a grounding tool [source: TOC; Vorwort].
• Steps: [synthesis] (1) "Now I notice…" rounds: outside (what I see and hear), inside (body sensations), thoughts. (2) Shift attention deliberately between these zones. (3) Practise for 2–5 minutes in session, then daily.
• Example language (illustrative): "Just say what you notice right now, starting with 'Now I'm aware of…'. Outside first, then inside."
• Watch for: Body focus triggering trauma memories. Start with external senses.

4.26 Methods of self-support and attachment support (10.2.2, 14.2)

• Purpose: Strengthen self-support and experiences of secure attachment [source: TOC].
• Steps: [synthesis] (1) Physical self-support: posture, feet, breath, a hand on the chest. (2) Inner supporting figures: a real or imagined person who stands by the patient. (3) Self-soothing statements. (4) Practise them before and after confrontation work.
• Example language (illustrative): "Who in your life has been on your side? Imagine them standing behind you. What changes in how you sit?"
• Watch for: No available attachment figures (use imagined or non-human ones, such as an animal or nature, which the authors accept as interaction partners [source: Ch. 1]).

4.27 Rumination (Grübeln) (14.5)

• Purpose: Interrupt repetitive "why / what if" thinking that keeps the trauma active [source: TOC 14.5].
• Steps: [synthesis] (1) Psychoeducation that rumination feels like problem-solving but is not. (2) Notice the onset. (3) Set a limited "worry time". (4) Switch to an activity or to the awareness exercise. (5) Turn recurring questions into an inner dialogue for the session (see 4.11).
• Example language (illustrative): "When the 'why' questions start, note them on paper and bring them here. Then go back to what you were doing."
• Watch for: Guilt-driven rumination. Address guilt directly (4.10).

4.28 Sleep hygiene (14.6)

• Purpose: Improve sleep, which PTSD often disturbs [source: TOC 14.6].
• Steps: [synthesis] (1) Keep regular sleep and wake times. (2) Have a wind-down routine. (3) Limit caffeine, alcohol and screens in the evening. (4) Keep the bed for sleep; if awake for a long time, get up for a while. (5) Have a plan for nightmares (grounding, light, orientation). Refer for medical review if severe.
• Example language (illustrative): "Let's look at your evenings and see what could help your body get ready for sleep."
• Watch for: Alcohol used as a sleep aid. Persistent nightmares (consider targeted treatment).

4.29 Anxiety experience (Angsterleben) (14.7)

• Purpose: Explain anxiety and its bodily signs to reduce fear of fear [source: TOC 14.7].
• Steps: [synthesis] (1) Draw the anxiety curve and the alarm system together with the patient. (2) Link bodily signs to the fight / flight / freeze response. (3) Show that avoidance keeps anxiety going while approach lets it fall.
• Example language (illustrative): "Your alarm system did exactly what it should then. Now it goes off too easily. Let's see how it works."
• Watch for: Psychoeducation delivered as a lecture. Link it to the patient's own examples.

4.30 Working with and on emotions (10.2.3, 14.3)

• Purpose: A toolbox of exercises for perceiving, regulating and expressing emotions, used in Phase II and IV [source: TOC].
• Steps: [synthesis] Emotion naming and body mapping. Rating emotion intensity. Expressing it through voice, posture or movement. Containment at the end of a session (for example, putting it aside in an imagined container until next time).
• Example language (illustrative): "Where in your body is the anger? How big is it, 0 to 10? Let's give it a sound."
• Watch for: Expression without containment. Always close.

4.31 Trust-building and movement (10.2.4, 14.4)

• Purpose: Rebuild trust in oneself and others through body- and movement-based experience [source: TOC].
• Steps: [synthesis] Grounded standing and walking. Choosing interpersonal distance (the patient sets how close the therapist sits or stands). Graded trust exercises the patient controls.
• Example language (illustrative): "Show me how close I can sit so it feels right for you today. Move my chair if you like."
• Watch for: Touch is not needed; avoid it unless explicitly agreed and appropriate. Movement can trigger body memories.

4.32 Building conflict and dialogue capacity; social-skills training (10.2.5)

• Purpose: Practise the dialogue and conflict skills needed to stand one's ground in relationships [source: TOC; Ch. 1].
• Steps: As 4.12 (role-play, feedback, real-life experiments) [synthesis].
• Example language / Watch for: As 4.12.

4.33 General competence building (10.2.6)

• Purpose: Strengthen general life competences (structure, activity, problem-solving) [source: TOC]. Details are not published outside the manual [uncertain].
• Steps: [synthesis] Schedule activities. Rebuild valued activities. Use structured problem-solving for current stressors.
• Example language (illustrative): "What did you used to enjoy that has gone missing? Let's pick one small piece for this week."
• Watch for: Overload. Keep the steps small.

4.34 Reflection and relapse prevention (Ch. 11)

• Purpose: Consolidate what changed and prepare for future triggers [source: TOC Ch. 11].
• Steps: [synthesis] (1) Review the journey together, phase by phase. (2) Name the patient's own most useful tools. (3) List high-risk times (anniversaries, court dates, media). (4) Write a personal relapse plan: early signs, what to do, whom to contact. (5) Agree booster options.
• Example language (illustrative): "If the old feeling of being small shows up again next year, what will you notice first, and what will you do?"
• Watch for: Unspoken fear of ending. Address it as a relationship theme.

4.35 Termination indicators and evaluation (Ch. 12, 13)

• Purpose: Decide together when to end and evaluate the outcome [source: TOC Ch. 12–13]. The manual's indicators are not published outside the manual [uncertain].
• Steps: [synthesis] Re-administer the baseline PTSD measure. Check the authors' broader aims as well: contact and dialogue capacity, self-acceptance, current relationships. Agree the end and any follow-up.
• Example language (illustrative): "Let's look at where you started and where you are now, both your symptoms and how you are with other people."
• Watch for: Ending only because the session limit is reached (the RCT capped sessions at 24) when key aims remain. Discuss continuing or referral.

5. Handling problems

5.1 What the manual covers. The manual names four difficulties in dialogical exposure: avoidance behaviour; activation of images or relationships; rational argumentation; and re-actualisation with emotional flooding [source: TOC 8.4.1–8.4.4]. It also discusses the risk of compliance [source: Ch. 1]. The manual's own responses to the four difficulties are not described in any public source [uncertain]. All responses below are therefore the writer's synthesis unless tagged otherwise [synthesis].

5.2 Avoidance in dialogical exposure (8.4.1). Signs: the patient talks about the figure instead of to it, changes the subject, looks away, keeps the figure very far away, or misses sessions before confrontation work. Responses:

• Name the avoidance without judging it, as a protective achievement in line with the authors' view of symptoms [source: Ch. 1].
• Ask what it protects against.
• Reduce the step: a greater distance, a cushion instead of a chair, eyes open, the therapist voicing the first sentence for the patient to try.
• Return to Phase II resources if the avoidance is driven by fear of collapse.
• Re-check consent, because avoidance can be a valid "not yet".

Illustrative: "You keep telling me about him rather than to him. That makes sense; it's safer. Would one sentence towards that chair be possible, from as far away as you like?"

5.3 Activation of images or relationships (8.4.2). [uncertain: the authors' meaning of this heading is not public.] Likely meanings: (a) during the dialogue other traumatic images or other relationships come up (an earlier abuser, a parent); (b) the patient cannot form any image of the figure.

• For (a): note the new figure and agree whether to stay with the current dialogue or switch. Avoid stacking several figures in one session. Earlier relational trauma may need its own Phase I–II work.
• For (b): use concrete anchors (a photo-like description, a symbolic object, a name card on the chair) or work with the situation (4.13) first.

5.4 Re-actualisation, emotional flooding and dissociation (8.4.4). Signs: distress near maximum, the patient behaving as if back in the event, hyperventilation, freezing, glazed eyes, losing track of the room. Steps:

1. Stop the dialogue.
2. Remove or cover the figure, or have the patient turn away from it.
3. Orient: use the patient's name, the date, the place, "you are here with me".
4. Ground the senses: feet pressing on the floor, naming objects in the room, a cold object or a strong scent, slow exhale.
5. Restore an upright, self-supporting posture.
6. Once the patient is present again, debrief briefly and normalise it.
7. Next session, reduce intensity: more distance, shorter segments, more resourcing. Consider returning to Phase I–II.

If dissociation is frequent, screen for a dissociative disorder and lengthen stabilisation. Do not end a session while the patient is still dissociated; check that they are safe to travel. Illustrative: "Stop here. Look at me. You're in my office, it's Thursday, you're safe. Press your feet into the floor. Tell me three things you can see."

5.5 Stuck clients. Signs: no change over several sessions, the same story repeated, chronic numbness.

• Check whether the work is in the right phase. It may be too early for confrontation, or the patient may be over-stabilised and avoiding it.
• Find the relationship the patient is keeping away from. The authors locate stuckness in a relationship held at a distance, and re-approaching it, for example through direct address of the lost person, released the impasse [source: Prolog].
• Make the here-and-now relationship explicit: "What is it like to sit here with me while nothing seems to move?"
• Review goals, including contact goals, not just symptoms.

5.6 Rational argumentation (8.4.3). Signs: in the dialogue the patient debates, explains or justifies ("he probably had a hard childhood"), and no feeling or contact develops.

• Name the shift from contact to argument.
• Ask for first-person, present-tense, direct statements of experience ("I feel… when…").
• Bring attention to the body.
• Shorten the sentences.
• If understanding the aggressor serves as protection, acknowledge that and ask what would happen without it.

Illustrative: "You're explaining him to me. Let's leave the explanations for a moment. What do you feel looking over there?"

5.7 Collapse into the old position during dialogue. Signs: the patient shrinks, apologises to the figure, or self-blame takes over.

• Pause and name the old pattern (submission as a past survival response; the authors' model [source: Ch. 1]).
• Physically change the position: stand up, move the figure further away, have the therapist stand beside the patient.
• Offer a sentence for the patient to try out ("You don't get to decide about me any more"). Only if they agree with it should they repeat it in their own words.
• If collapse repeats, return to Phase II self-support and assertiveness work.

5.8 Compliance and pseudo-improvement. The authors warn that patients may comply and present their improvement more favourably, out of fear of exclusion [source: Ch. 1].

• Invite disagreement explicitly ("What did I get wrong today?").
• Notice too-quick agreement.
• Use a standardised measure alongside the conversation.
• Value it when the patient says no to an exercise.

5.9 Ruptures. Because DET treats therapy as relationship therapy [source: Ch. 1], ruptures are material for the work.

• Name what happened between you.
• Take your share of responsibility.
• Ask about the patient's experience.
• Link it to their relational pattern only if they find that useful.
• Common triggers: the patient felt pushed into confrontation, felt their loss was minimised, or felt the therapist sided with "understanding" the perpetrator.

5.10 Non-adherence between sessions. Explore the obstacles (forgetting, avoidance, shame, practical problems). Make tasks smaller and more concrete. Start them in session. Reframe them as experiments, not tests. Check whether a task conflicts with the patient's protective strategies.

5.11 Role-play reluctance ("this feels silly"). This difficulty is specific to dialogue methods.

• Explain the rationale: the inner relationship is real and is easier to change when it is enacted.
• Offer graded formats: talking about it, then speaking to an imagined figure with eyes closed, then using an empty chair.
• Model it briefly yourself.
• Respect a no, and work imaginally instead.

5.12 Suicidality. Death wishes are common after traumatic loss (the Prolog patient reported one) [source: Prolog].

• Assess suicidality directly at intake and whenever grief or reunion wishes are activated, using current standard risk assessment.
• Agree a safety plan, including lethal-means counselling (safe storage or removal).
• Postpone confrontation work while risk is acute.

5.13 Ongoing perpetrator contact, legal proceedings or current danger. Prioritise real safety. Do not run dialogical exposure while the patient is still exposed to the perpetrator. Inform patients facing court that intensive memory work may affect testimony, and coordinate with their lawyer as appropriate. The legal-proceedings point comes from a secondary German source and is not from the DET manual [source: Müller reading sample; synthesis].

5.14 Complex or childhood trauma. The trials used single-event trauma in adulthood [source: Butollo et al. 2016]. The authors say they use the model with complex trauma outside the trials [source: Vorwort]. For these patients:

• Expect longer Phase I–II work and more relational ruptures.
• Introduce dialogue with caregiver-perpetrators especially gradually.
• Watch for the patient's loyalty conflicts.
• Screen for dissociative disorders.

5.15 Therapist pitfalls.

• Pushing towards confrontation for the sake of the protocol.
• Over-identifying with the patient's anger against the perpetrator.
• Avoiding strong affect yourself.
• Treating the role-play figure as the real person, or encouraging real-life confrontation without a safety analysis.
• Using suggestion to shape memories. Treat the material as the patient's experience, never as historical truth to be uncovered.

Get supervision in Gestalt or psychodrama chair work before using dialogical exposure; published training details for DET are lacking [uncertain].

Sources

Web pages:

• Butollo & Karl (2012), Dialogische Traumatherapie – Leseprobe (Klett-Cotta reading sample: TOC, Vorwort, Prolog, start of Ch. 1)
• Dialogische Traumatherapie – Leseprobe (e-book sample, lesejury.de)
• Butollo, Karl, König & Hagl (2014), Dialogical exposure in a gestalt-based treatment for PTSD, Gestalt Review 18(2):112–129 – abstract (gestaltresearch.org)
• KU.edoc record of the Gestalt Review paper
• Butollo, König, Karl, Henkel & Rosner (2014), Feasibility and outcome of DET for PTSD: pilot study with 25 outpatients, Psychotherapy Research 24:514–521 – abstract (gestaltresearch.org)
• KU.edoc record of the pilot study
• Butollo, Karl, König & Rosner (2016), RCT of DET versus CPT, Psychotherapy and Psychosomatics 85:16–26 – Karger abstract
• KU.edoc record of the RCT
• LMU Open Access record of the RCT
• LMU Open Access: publications of Regina Karl
• ClinicalTrials.gov NCT01693497, Comparison of CPT and DET for PTSD (trial registration)
• Müller, G., Einführung – grundsätzliche Überlegungen zur Traumakonfrontation und -integration (reading sample, secondary; used only for general contraindications)

Further web pages:

• König, J. (2012), LMU dissertation on the CPT arm of the DET vs CPT trial
• KU.edoc record: Hagl, Powell, Rosner & Butollo (2015), Dialogical exposure with traumatically bereaved Bosnian women
• gestaltresearch.org: Willi Butollo publication list

Books and papers cited:

• Butollo, W., & Karl, R. (2012). Dialogische Traumatherapie: Manual zur Behandlung der Posttraumatischen Belastungsstörung. Stuttgart: Klett-Cotta (Leben Lernen 256).
• Butollo, W., Karl, R., König, J., & Hagl, M. (2014). Dialogical exposure in a gestalt-based treatment for posttraumatic stress disorder. Gestalt Review, 18(2), 112–129. doi:10.5325/gestaltreview.18.2.0112. Abstract only.
• Butollo, W., König, J., Karl, R., Henkel, C., & Rosner, R. (2014). Feasibility and outcome of dialogical exposure therapy for PTSD: a pilot study with 25 outpatients. Psychotherapy Research, 24(4), 514–521. doi:10.1080/10503307.2013.851424. Abstract only.
• Butollo, W., Karl, R., König, J., & Rosner, R. (2016). A randomized controlled clinical trial of dialogical exposure therapy versus cognitive processing therapy for adult outpatients suffering from PTSD after Type I trauma in adulthood. Psychotherapy and Psychosomatics, 85(1), 16–26. doi:10.1159/000440726. Abstract only.

Also cited:

• König, J. (2012). Cognitive Processing Therapy in der Behandlung der Posttraumatischen Belastungsstörung: Untersuchung des kognitiv-verhaltenstherapeutischen Arms einer Therapievergleichsstudie zur Dialogischen Exposition in der Traumatherapie. Dissertation, LMU München.
• Hagl, M., Powell, S., Rosner, R., & Butollo, W. (2015). Dialogical exposure with traumatically bereaved Bosnian women: findings from a controlled trial. Clinical Psychology & Psychotherapy, 22(6), 604–618. doi:10.1002/cpp.1921.