What is narrative exposure therapy (NET)?

^{A cartoon doctor and patient. The patient is thinking of a timeline, beginning with ‘birth’ and ending with ‘present moment’. Between these two are various entries marked as either events or traumas.}

What does narrative exposure therapy involve?

In narrative exposure therapy (NET), individuals are encouraged to establish a coherent life story by reflecting on key life events and contextualising the traumatic experience(s).

NET can be effectively delivered in a range of settings such as community settings, and with a range of populations such as refugees, offenders and veterans. NET is often delivered in small groups, which makes it a viable therapeutic option for low-resource settings.

NET involves supporting the individual in telling their life story chronologically, focusing on both positive and negative life events, describing those experiences in detail, and focusing on feelings and emotions that those events arouse.

What is the aim of NET?

The ultimate aim of the therapy is to help the individual restore a positive self-identity and meaningfully integrate the traumatic event(s) into a coherent life story.

Key therapist attributes include compassionate understanding, active listening, therapeutic alliance and unconditional positive regard.

NET in low- and middle-income countries

There is evidence from smaller-scale studies that NET may be effective for reducing PTSD and related psychological and comorbid symptoms in a range of post-conflict settings such as Uganda, Rwanda and Sri Lanka (Cooper et al., 2019).

It has been also demonstrated that NET can be disseminated by trained lay health workers in low-income settings. This delivery approach is sometimes called ‘task shifting’ or ‘task sharing’.

Task shifting

Task shifting can enhance the capacity of developing countries to reduce the treatment gap for PTSD and other mental disorders by increasing the trained mental health workforce-professional and paraprofessional.

^{The image shows tents in a refugee camp. Source: Pixabay.com}

Implications beyond the individual

Because NET can be implemented beyond the individual level, its use may have important implications for family and community functioning, particularly in low-resource settings.

It is recognised that traumatic stress can be intergenerational, meaning it can be passed on from generation to generation and that it can have severe consequences for family and community cohesion. Therefore, the involvement of the family and the community in the treatment of trauma and PTSD seems integral to individual and collective wellbeing (Cooper et al., 2019).

NET has been successfully delivered in community settings by non-governmental organisations and by trained members of the community. Cooper and colleagues highlight that benefits to the Ugandan community, for instance, have included reductions in PTSD symptoms and increases in the mental health capacity of the country.

A short video resource reinforcing the main features and uses of NET is offered by Cooper, Wieling and Pfeiffer.

Limitations of NET

Larger-scale studies with more diverse samples are needed to support the effectiveness of NET in a range of contexts. Also, its effectiveness in treating comorbid mental health problems such as depression and substance use remains uncertain.

Furthermore, providing NET can be emotionally taxing on therapists. Therefore, therapists will benefit from supervision and peer support.

Another challenge in delivering NET relates to the extremely sensitive nature of service-users disclosures during the therapy sessions, which can often be emotionally overwhelming.

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‘’Trina was a 30-year-old African American, lesbian female, unemployed, and living with her mother and daughter in a small apartment. Trina had multiple marginalised identities and was born into a disadvantaged social context […]. Trina also experienced numerous traumatic events throughout her life. As a child, she experienced ongoing physical abuse from her father and witnessed intimate partner violence between her mother and father. […] In addition, 6 months prior to our first session, Trina had left a physically and emotionally abusive relationship that lasted over 10 years. Trina reported experiencing high levels of anxiety, occasional ‘panic attacks,’ and difficulty focusing and controlling her emotions. […] Trina had begun to distance herself from friends and avoided places or events where there might be loud noises. She also described having difficulty sleeping, waking up several times throughout the night, and frequent nightmares of her traumatic experiences.’’

The case study, adapted from Cooper and colleagues (2019), outlines the application of NET with an individual who has endured multiple and complex traumas. The following therapeutic techniques can be engaged by the therapist:

• A formal clinical assessment for PTSD symptoms.
• Completion of a Lifeline activity. This involves asking the individual to ‘plot’ significant life events on a written timeline and discussing each traumatic event in a safe, supportive and empathetic environment. The therapist asks for clarification of any details if needed.
• Engagement with imaginal exposure. During this activity, the therapist reads the timeline events aloud to the individual in chronological order, exposing each traumatic event and allowing the integration of affective, cognitive, physiological and sensory details into the present moment.
• Prioritising safety. The therapist ensures the individual feels safe and supported, and is willing to continue the exposure to traumatic events.
• Exploration of the individual’s hopes and dreams for the future.

References

^{American Psychological Association. (2017). Narrative Exposure Therapy (NET). Retrieved from https://www.apa.org/ptsd-guideline/treatments/narrative-exposure-therapy#:~:text=Narrative%20exposure%20therapy%20is%20a}

^{Cooper, D. K., Wieling, E., & Pfeiffer, A. (2019). Bioecological implications of narrative exposure therapy in Low‐Resource settings: Individual, family, community, and Socio‐Political contexts. Australian and New Zealand Journal of Family Therapy, 40(4), 353-367. doi:10.1002/anzf.1392}