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Effects of Narrative Exposure Therapy on PTSD, depression, and insomnia: A study with traumatized North Korean refugee youth

Jinme Park and Thomas Elbert

March 30, 2020

North Korean refugee youth typically have been exposed to multiple traumatic experiences in their home country and during their flight (Park et al., 2019a). Consequently, they have high rates of trauma-related mental disorders including posttraumatic stress disorder (PTSD) and depression. Individuals diagnosed with PTSD frequently report the inability to obtain a normal sleep. The severity of PTSD symptoms correlates with disturbed sleep and insomnia, a relation that seems mediated through depression (Park et al., 2019b). The frequent depression in North Korean refugee youth with PTSD (Park et al., 2019b) may thus explain their elevated levels of sleep problems. Therefore, treating PTSD and depression of North Korean refugee youth may be important to reduce dysfunctional sleep patterns and insomnia.

Narrative exposure therapy (NET; manual Schauer, Neuner, & Elbert, 2005, 2011) is a trauma-focused intervention, developed to address PTSD and mental distress resulting from the exposure to multiple traumatic stressors. NET substantially reduces the severity of PTSD symptoms and related mental health problems such as depression, dissociation, and anxiety. However, it has not been tested whether trauma-related disorders can be successfully treated in North Korean refugees with their complex history of exposure to violence (Park et al., 2019a). Moreover, to date, no studies have addressed the effect of NET on sleep and insomnia of severely traumatized survivors. The aim of this study was to examine whether NET can more effectively address PTSD, depression, and sleep problems than non-trauma-focused treatment that has so far been the common treatment for North Korean refugee youth.

Twenty North Korean refugee youth diagnosed with PTSD were assigned to either a treatment group with NET or a control group, who was offered non-trauma-focused treatment (supportive therapy or art therapy). In the NET group, participants received five to 10 individual sessions (M: eight, 90-120 min per session) conducted by a trained therapist. The control group obtained 10 to 15 individual sessions (40-60 min per session) and one session of education about sleep disorders led by a psychiatrist with substantial experience in this field. Changes in insomnia and sleep quality in addition to PTSD and depression of the two groups were assessed before treatment, and three months and six months post-treatment. Participants treated in the NET group showed more clinically meaningful changes in the diagnostic status for PTSD and more reductions in PTSD, depression, and sleep problems compared to those in the control group. First, all refugee youth treated in the NET group had lost their diagnostic status, whereas 45% of the control group were still diagnosed with PTSD. Second, in contrast to the control group, refugee youth who were given NET showed no remaining clinically relevant symptoms of depression and no residual sleep problems.

This strong treatment effect of NET on PTSD, depression, and sleep problems suggests that NET is more effective than the non-trauma-focused treatment for addressing trauma-related problems in North Korean refugee youth. The substantial improvement of sleep in the NET group was associated with reduced PTSD and depression symptoms. We conclude that NET can be a useful psychotherapeutic intervention for traumatized North Korean refugee youth and suggest that it may also be effective for the treatment of sleep problems arising from traumatic experiences.
 

References

Park, J., Catani, C., Hermenau, K., & Elbert, T. (2019a). Exposure to Family and Organized Violence and Associated Mental Health in North Korean Refugee Youth compared to South Korean Youth. Conflict and Health, 13, 46. doi: 10.1186/s13031-019-0230-0

Park, J., Elbert, T., Kim, S. J., & Park, J. (2019b). The Contribution of Posttraumatic Stress Disorder and Depression to Insomnia in North Korean Refugee Youth. Frontiers in Psychiatry, 10, 211. doi: 10.3389/fpsyt.2019.00211

Schauer, M., Neuner, F., & Elbert, T. (2005). Narrative Exposure Therapy - a short term intervention for traumatic stress disorders after war, terror or torture. Cambridge, MA: Hogrefe & Huber.

Schauer, M., Neuner, F., & Elbert, T. (2011). Narrative Exposure Therapy (NET). A Short-Term Intervention for Traumatic Stress Disorders (2nd ed.). Cambridge/ Göttingen: Hogrefe & Huber.
 

Reference Article

Park, J. K., Park, J., Elbert, T., & Kim, S. J. (2019). Effects of Narrative Exposure Therapy on PTSD, depression, and insomnia: A study with traumatized North Korean refugee youth. Journal of Traumatic Stress.
 

Questions for Discussion

  1. Is trauma-focused treatment (reorganization of traumatic memories) a prerequisite to normalize sleep in traumatized individuals? Should it be the first-line treatment for insomnia?
  2. Does depression intensify sleep problems in traumatized individuals or do sleep problems aggravate depression? A vicious cycle?
 

About the Authors

Jinme Park is a clinical psychologist and doctoral student in the Department of Psychology at the University of Konstanz. She has a history of serving community-based individuals and refugee youth through individual therapies focused on treating traumatic stress. Her interests include the development and implementation of trauma-focused interventions for severely traumatized survivors including North Korean refugees.

Thomas Elbert is a Professor Emeritus of Clinical Psychology and Behavioural Neuroscience at the University of Konstanz and a Hector Fellow. He has studied the consequences of social and traumatic stress in the laboratory and also in crisis regions in Africa and Asia where he developed NET together with Dres Neuner and Schauer. Elbert is a member of the German National Academy of Sciences, the Berlin-Brandenburg Academy of Sciences and holds honorary professorships at the Université Lumiére in Burundi and the Mbarara University of Science and Technology in Uganda.