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Home > Public Resources > Trauma Blog > 2016 - February > Clinician’s Corner: I Want to Hear Your Story: The Identity of Narrative Exposure Therapy

Clinician’s Corner: I Want to Hear Your Story: The Identity of Narrative Exposure Therapy

February 2, 2016

Narrative Exposure Therapy (NET) is an evidence-based therapy for posttraumatic stress disorder (PTSD) that has been developed by Maggie Schauer, PhD, Thomas Elbert, PhD and Frank Neuner, PhD at the University of Konstanz in Germany. Confronted with a large number of refugees during the Balkan wars in the late 1990’s this team identified the need for a short and pragmatic treatment approach. While NET was originally developed for victims of war and torture, variants of NET have recently been tested for victims of child abuse as well as perpetrators of crimes, violence and atrocities.

NET is a short-term treatment approach that consists of a flexible number of four to 14 individual sessions of 90 minutes, depending on the requirements of the setting. The core procedure of NET is the reconstruction of the client’s life history. The client and the therapist create a written autobiography containing the major emotional memories from birth to the present. In the lifeline exercise, the client identifies the chronological sequence of positive, negative and traumatic events across their lifespan by placing flowers and stones as symbols on a rope that has been laid out on the floor.

The focus of the NET is on reconstructing the fragmented memories of traumatic experiences into coherent narrations that are connected to the temporal and spatial context of the life period. At the end of treatment, a copy of the final consistent life narration is handed over to the client, and the therapist keeps one copy that may, depending on the interest of the client, be used for human rights purposes (see Schauer, Neuner, & Elbert, 2011 for the current manual).

NET starts with an assessment and measurement of PTSD symptoms and comorbidities, followed by psychoeducational preparation of the client. In this essential step of the treatment, the therapist normalizes PTSD symptoms and explains the memory theory of PTSD as the rationale of treatment. The education is adapted to the educational and cultural background of the client and consists of explanations that range from metaphors to detailed scientific presentations.

NET shares many similarities with other effective treatment approaches, especially those that contain elements of exposure to trauma memories. However, some specific NET principles and procedures may make it more appealing and effective for some clients in some contexts than other trauma-focused therapies. Among the different variants of trauma therapies, the specific characteristics of NET can be characterized as follows.

1. Life-span Perspective Instead of Focus on Index-trauma

Most trauma-focused treatment approaches require the client to identify the most traumatic event, or what is often referred to as the index-trauma. However, victims of wars and persecution, just like victims of child abuse, have often experienced a series of traumatic events rather than single traumas. It is often difficult if not impossible for them to decide which of the horrific experiences has been the most detrimental. Often, whole periods of the life are rated as traumatic. This can commonly be observed in assessment when clients insist on referring to “the war” or “the imprisonment” rather than a single specific event as reference of their posttraumatic symptoms.

A key assumption of NET is that it is the accumulation of aversive events and conditions over the life-span that causes posttraumatic stress symptoms and brings about pathological memory representations. Without the need to estimate the relative effect of single episodes in life, the client is invited to recount the story of his full life and to identify traumatic events and episodes in this process.

This procedure is based on the recent hypothesis that the working agents of exposure are not habituation and extinction but the contextualization of dysfunctional conditioned emotional responses (Craske et al., 2008). Following this rationale, the aim of NET is to locate the hot memories of traumatic events into the cold context of autobiographic memory. The client learns that certain massive emotional, physiological and cognitive responses had been adaptive and meaningful survival reactions in specific moments and situations in the past, but do not fit the demands of their current situation.

The reconstruction of the autobiographic memory fulfills another purpose. Many victims of complex trauma histories are unable to provide narrations of extended periods of their life, sometimes even their whole childhood. However, a meaningful autobiographic memory representation is a key characteristic of our identity, as it informs us how we have developed our personality with all its strengths and weaknesses. The NET process allows the creation of meaningful relationships between current behavior and the past and builds semantic bridges between the single emotional experiences. In turn, through this biographical approach, NET supports self-understanding and self-acceptance.

2. Advocacy for Survivors Instead of Therapeutic Neutrality

Psychological trauma comes along with speechlessness. Due to fragmented autobiographic representations, avoidance behavior and feelings of shame as well as trauma-related feelings of helplessness and inferiority, victims of violence often have difficulties expressing themselves and talking about their experiences. This silence is a double-sided phenomenon, as the society and public is also dominated by avoidance of the stories of trauma survivors. However, maintaining and improving human rights requires understanding and acknowledging the destructive power of human rights violations. In this perspective, NET can provide the comprehensible documentations of single fates that allow sympathizing with the victims. Individual narrations of the cruelties of war and torture can counteract belittlement of the pain and suffering caused by violence, and may motivate societies to prevent and stop wars and to taboo torture practices. For the victims, regaining access to their biography and communicating their history to others may empower them to stand in for their rights as victims of violence.

At the same time, communicating personal emotional life events is one of the most powerful ways to create closeness in relationships. Once the client reconstructs his/her past and receives compassion from the therapist, he or she will find it easier to disclose and to relate to others and reduce their feelings of shame, detachment and loneliness.

3. Task-shifting Instead of Regulation in Application and Dissemination

Originally, NET has been developed for the application in low-income countries affected by war and human rights violations. In such a context, any treatment approach has to be pragmatic, short, and easy to learn. The World Health Organization recommends a task-shifting approach for such countries with an insufficient health sector. A series of randomized controlled trials has proven that NET can be successfully applied by trained lay therapists without any medical or psychological background (for example, teachers and fellow refugees in a refugee camp; Robjant & Fazel, 2010).

The successful and sustainable application of trauma therapy in regions where PTSD point prevalence rates reach up to 40 percent, the health care system has to be rethought. A proper and hierarchical structure that includes different levels of care with different qualifications and systems of referral, supervision and monitoring are necessary. Within such a system, NET can be provided by lay counselors after a relatively short training.

In a recent randomized trial, it could be shown that local NET therapists can successfully train the next generation of therapists within a train-the trainer model (Jacob, Neuner, Maedl, Schaal, & Elbert, 2014), which is a further step to make expatriate therapists dispensable in the process of providing trauma treatment in low income countries. The current refugee crisis in Germany shows that specific situations can require a rethinking of health care even in countries with a first class health provision. It is difficult to find any alternative to a task-shifting approach to take care of one million refugees – about one quarter of them with PTSD - arriving this year alone.

4. Cross-cultural Approach Instead of Culture Specificity

One of the basic assumptions of NET is that with some cultural specifies in the expression of symptoms, trauma reactions are universal phenomena as they result from neurobiological processes involved in the processing of threat and stress. At the same time, sharing personal histories is a universal personal and social practice to cope with life events and to foster interpersonal closeness. This is the reason why the NET procedure can be successfully applied across cultures. While diagnostic instruments need to be carefully adapted for each language, only minor modifications in the NET procedure are required. At the same time, each culture presents with a wide variety of values, attitudes as well as economic and educational backgrounds and any treatment approach has to be adjusted to the individual needs of each single patient. Divisions between countries and continents are not necessarily helpful to classify the individual patterns of thoughts and experiences that are the basis for treatment.

5. Trauma-focus Instead of Humanitarian Holism

Representatives of trauma-focus therapies in regions affected by mass trauma have often been criticized for neglecting the true requirements of the populations. This argument is based on a misunderstanding, as NET is a treatment of trauma-related psychological disorders that has not been conceptualized as a comprehensive heal-the-world program. Clinicians and representatives of aid organizations have often suggested to strengthen resources such as security, trust, educational perspectives and social cohesion to foster recovery from trauma. It is beyond dispute that war-affected populations need assistance on different levels and that it is essential to improve security and to reduce ongoing stress for traumatized populations. At the same time it remains to be empirically proven that academic, economic, social or holistic psychosocial interventions reduce trauma-related disorders. In all crisis regions where we have worked, we have observed a lack of professional assistance for victims with severe PTSD and other mental disorders. It is likely that individuals with the most severe presentations of these disorders do not profit from other measures but require and deserve evidence-based therapy. NET is a promising tool in such a context, not more, but also not less.

About the Author

Professor Dr. Frank Neuner, PhD, is a licensed psychotherapist, who has carried out the first randomized controlled trial of NET in Uganda as his PhD thesis at University of Konstanz, supported by Maggie Schauer and supervised by Thomas Elbert. He is a founding member of the aid organization, vivo. Since 2008, he has served as a Professor of Clinical Psychology and Psychotherapy at Bielefeld University and director of the Bielefeld University Outpatient Clinic for Psychotherapy.

References

Craske, M. G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury, N., & Baker, A. (2008). Optimizing inhibitory learning during exposure therapy. Behaviour Research and Therapy, 46, 5-27. doi:10.1016/j.brat.2007.10.003

Jacob, N., Neuner, F., Maedl, A., Schaal, S., & Elbert, T. (2014). Dissemination of psychotherapy for trauma spectrum disorders in postconflict settings: A randomized controlled trial in Rwanda. Psychotherapy and Psychosomatics, 83, 354-363. doi:10.1159/000365114

Robjant, K., & Fazel, M. (2010). The emerging evidence for Narrative Exposure Therapy: A review. Clinical Psychology Review, 30, 1030-1039. doi:10.1016/j.cpr.2010.07.004

Schauer, M., Neuner, F., & Elbert, T. (2011). Narrative exposure therapy (2 ed.). Seattle: Hogrefe.