Thursday, June 30, 2016

Storytelling is Good Medicine

We are all storytellers.

Narrative Exposure Therapy (NET)
A trauma-specific and evidence-based intervention for adults & children
pictured here in Sri Lanka
Placing the rocks on those periods of the autobiographical story
pictured here in Uganda

Telling the Story

Lifeline with rocks and flowers moments

Narrative Exposure Therapy (NET) was developed for use with refugees. It is a combination of Cognitive behavior therapy and Testimony therapy. Studies have shown NET to be effective with both adults and children. It has been used all over the world. It was used in China with victims of the earthquake.

NET is a process that can teach and help people to tell the story of their trauma in order to become more resilient. Narrative is an important resilience skill. Telling the story can help rebuild meaning structure after a traumatic event. Resilience is linked to making sense of the traumatic event.

Here is an abstract from a peer-reviewed journal article about 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.

NET is a manualised treatment (that means there is a book or manual that describes in step-by-step detail how to conduct the intervention).

Step 1:
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.

Step 2:
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.

First Session:
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).

Second Session:
Following the first 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.

Third, Fourth and Subsequent Sessions:
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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