Monday, November 5, 2012

Narrative Exposure Therapy (NET)

Working in South Los Angeles where most students are exposed to multiple traumatic events and half endorse traumatic stress, depressive and anxiety symptoms in the clinical range, I wondered what is done in war-torn countries to treat trauma?  Because addressing this through individual or small group (6-8 students) interventions by mental health professionals seems burdensome and unfeasible.

Apparently, TEN years ago a short-term intervention to reduce PTSD symptoms among civilians living in low-income and war-torn countries was developed and shows very positive and sustained outcomes among adults AND children.  

Further, "both mental health professionals and lay counsellors can deliver NET....[a] study demonstrated how lay counsellors recruited from the local area and trained to deliver NET had results equivalent in efficacy to trials in which NET was delivered by mental health professionals...The lay counsellors who provided both types of therapy were recruited from the local community and were trained for six weeks." 

As if all that were not interesting enough, NET aims to create an autobiographical account of a traumatized persons life - with details, coherence, organization, order, the good and bad - which may not only be effective in reducing PTSD symptoms.  Given what we know about the nature of a parents narrative of their childhood being a good predictor of the quality of attachment security with their children, NET may also prove to be effective in increasing attachment security between traumatized parents and children (which we know is a mediator and moderator of PTSD development) - that will be my next research question...

Attached is an abstract and excerpt from an article that describes the research evidence and steps in conducting Narrative Exposure Therapy (NET).


Individuals who have experienced multiple traumatic events over long periods as a result of war, conflict and organised violence, may represent a unique group amongst PTSD patients in terms of psychological and neurobiological sequelae. 

Narrative Exposure Therapy (NET) is a short-term therapy for individuals who have PTSD symptoms as a result of these types of traumatic experiences. 

Originally developed for use in low income countries, it has since been used to treat asylum seekers and refugees in high-income settings. 

The treatment involves emotional exposure to the memories of traumatic events and the reorganisation of these memories into a coherent chronological narrative. 

This review of all the currently available literature investigates the effectiveness of NET in treatment trials of adults and also of KIDNET, an adapted version for children. Results from treatment trials in adults have demonstrated the superiority of NET in reducing PTSD symptoms compared with other therapeutic approaches. 

Most trials demonstrated that further improvements had been made at follow-up suggesting sustained change. 

Treatment trials of KIDNET have shown its effectiveness in reducing PTSD amongst children. 

Emerging evidence suggests that NET is an effective treatment for PTSD in individuals who have been traumatised by conflict and organised violence, even in settings that remain volatile and insecure.

Conducting NET

NET is a manualised treatment. The patient first undergoes psychoeducation in which the theoretical underpinnings of PTSD and the process of NET and rationale for treatment are explained. Psychoeducation about how avoidance of reminders of traumatic events is a key feature of PTSD, and the impact of this on inhibiting treatment, is provided. Once informed consent has been obtained, the therapy can begin. Sessions are usually 60–120 min in length and ideally occur in close succession preferably with one or more sessions per week and a maximum of a fortnight between sessions.

In the first session the patient constructs the ‘lifeline’. This is a physical representation of their life using a rope, beginning at birth and ending at the present day, with a section of the rope left uncoiled representing the future. The patient then briefly goes through their life, in chronological order, placing a symbol (e.g. flowers of different shapes and sizes) on the line to represent happy events and a different symbol (e.g. stones) for sad or frightening events. The therapist's role is to ensure the correct chronology of these events. The lifeline is useful in establishing the therapeutic relationship and in providing an indication of the number of sessions that may be necessary to address all traumatic events (although some events may only be disclosed later in therapy).

Following this session, subsequent sessions are dedicated to the narration of the person's life, in chronological order, with particular focus on and attention to the traumatic events. Periods between events are described in brief to contextualise the traumatic events within the individual's life and produce a coherent narrative. On approaching a traumatic incident, the focus is on contextual information, firstly establishing what life was generally like at that time (where was the person living, what were they doing, what was a typical day) and then narrowing this down as precisely as possible to what happened when the event occurred. The traumatic events are then narrated in great detail, gently resisting the patient's attempt to hurry through or avoid emotional engagement with the memory

The patient then slowly narrates their traumatic experience in chronological order, as they experienced it at the time. They are encouraged to describe all sensory modalities along with their thoughts and feelings. The aim of NET is to connect the hot memories into the corresponding information held within the cold memory for the event and so the patient must be emotionally involved in the narration but must also put these experiences into words, constantly integrating the contextual information. At the same time as the narration of the traumatic event progresses, the patient's current physical, emotional and cognitive reactions are observed and verbalised. The therapist continually guides the patient back and forth between what is happening for the patient at the time of the narration (present time) and what occurred at the time of the event.  One of the aims of the therapy is for the person to be emotionally exposed to the memory of the event for sufficient time that habituation occurs and their emotional response to the memory is diminished over the course of therapy. However, this is unlikely to occur within a single session. The session ends at a safe point in the narrative, at the end of a traumatic event, once the therapist has ensured that the patient's arousal has diminished and that their emotional state is improved. The events in the period after the traumatic incident are narrated to help the patient place the episode in context.

The narrative as described in the session is written up by the therapist between sessions, this provides an opportunity for the therapist to ensure they have fully understood the details and chronology of the events described and therefore highlights areas in the story which do not seem as coherent and possibly need further exploration at the next session.

At the beginning of the next session the narrative from the previous session is read to the patient to ensure accuracy, once again expose the patient to memories of the event, elicit further information and promote integration of the hot and cold memories. Usually the patient notices a reduced physiological and affective reaction from the first session, although several sessions may be necessary for habituation to occur for severely traumatic events. 

At the end of the re-reading of the narrative, the period between this event and the next traumatic event is briefly narrated, before moving forward to the next traumatic episode, which is again narrated in intricate detail. This process continues until all stressful events have been narrated and the affective responses to the memories have reduced. At this point, the patient and therapist will have created a testimony of the person's life from birth to the present day, with a detailed narration of the traumatic events

At the end of the therapy some time is spent discussing hopes and aspirations for the future, following which all parties who have been involved in the therapy (including the patient, therapist and interpreter) sign the completed testimony. The patient receives a copy of this for their own private records and the authors report that it is common to find patients sharing their testimonies with others including lawyers and human rights organizations.

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