Narrative Exposure Therapy

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Colorado State University, Fort Collins *

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Sociology

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Feb 20, 2024

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1 Narrative Exposure Therapy (NET) Jenelle Clark Department of Social Work, Colorado State University SOWK 677-801, Trauma-Informed Care Prof. Sofia Webb April 26, 2023

2 Narrative Exposure Therapy The stories we tell ourselves about the experiences we go through in life carry tremendous power. They can even shape the way we process traumatic events, either helping us to integrate our experiences and heal or preventing us from moving on. Narrative Exposure Therapy (NET) is a type of short-term psychotherapy that uses the potency of storytelling to treat individuals and groups who have experienced trauma (American Psychological Association, 2017). It has been found to be particularly helpful for people who are healing from complex or multiple traumas and is frequently used to treat populations who have experienced war and violence. Description and Overview of NET NET was developed by a team of German psychotherapists working with people who had experienced war traumas in the late 1990s (Köbach, 2021). Dr. Frank Neuner, Dr. Maggie Schauer, and Dr. Thomas Elbert realized through sharing research and their anecdotal experiences in supporting survivors that traumatized people desperately wanted to tell their stories, but found it incredibly difficult to summon the words needed to speak to what they had experienced. This phenomenon is referred to as “speechless terror” and describes how high arousal can disrupt the part of the brain known as the Broca’s area that allows us to put our emotions into words (van der Kolk & The Meadows, 2006). High arousal can also impact the storing of memories and prevent an individual from having access to a coherent sense of what has happened to them. Narrative Exposure Therapy aims to address these trauma impacts and restore a sense of a cohesive narrative around the events that have impacted a person’s life and their ability to live in the present moment. NET draws on principles of both cognitive-behavioral therapy and exposure therapy with the main therapeutic goal of creating a greater sense of integration for the person who has experienced trauma (Identity On the Line, 2022). It does this by helping the client to place the source of presently-felt distressing somatic symptoms, emotions, and fragments of memory in the past and build a grounding, autobiographical narrative that captures the details of that experience in time and space, within the context of a full lifespan narrative. This can allow the person and their nervous system to feel the passage of time, limit the intrusive trauma-related symptoms, and come into a more present state of mind and being, understanding that the traumatic event has passed and that healing and safety can be created in the here and now. Major Treatment Components By telling the story of one’s life and having it witnessed by another person in a safe and caring therapeutic environment, the events that were stressful and traumatic can be recontextualized, empowering the individual to witness their own growth and resilience (Narrative Exposure Therapy Institute, n.d.). Meaning-making is at the heart of this therapy, and so the first step in NET is to build a cohesive lifeline with the client, allowing them to reconstruct in chronological order all the important events in their autobiographical and episodic memory. Building the lifeline is a physical process, bringing the individual’s internal timeline into the external world. This involves laying out a physical lifespan map, typically using materials like string or rope to represent linear time, stones to represent traumas and challenges, and flowers to represent beautiful and positive moments (Identity On the Line, 2022).

3 The therapist and the client then go through the timeline in progressive sessions, typically around four to twelve, processing each event in chronological order and using storytelling to construct a cohesive, meaningful thread (Schauer et al., 2011). This process is both iterative and cyclical. It involves taking the client through a cycle of questions aimed at collecting greater detail and deeper meaning from often fragmented memories (Identity On the Line, 2022). This process moves from sensory perception (What did you experience?), to cognition (What were you thinking about?), to emotion (How did this make you feel?), to physiology (How was your body reacting?), and finally to meaning (How can I interpret this?). After going through this cycle the therapist may recognize a need to ground in the present moment and provide cues to the client that they are not back in the traumatic experience, they are only talking about it. By establishing again and again a baseline in the present moment, this can allow the client to delve into the challenging memories without becoming overwhelmed or retraumatized. After the end of session, the therapist will write up a transcript of the narrative that the client provided. In the following session, the therapist and the client will read the transcript, and if nervous system activation happens again, the therapist will re-engage the storytelling cycle with the client to gain more detail and clarity around the event (Identity On the Line, 2022). Sessions are typically ninety minutes to provide adequate time to fully explore each memory, and at the end of the therapeutic relationship, the client is provided with the cohesive lifespan narrative that they created. The key components of Narrative Exposure Therapy include (Schauer et al., 2011): ● Exposure - Clients are encouraged to recount their traumatic experiences in a detailed and chronological manner. This process helps them to confront and process the memories of the events in a safe and controlled environment. The therapist provides a supportive and non-judgmental space for the client to share their story. ● Contextualization - The therapist helps the client to place their traumatic experiences within the broader context of their life story. This involves exploring the client's personal history, including their upbringing, family, culture, and other relevant life events. By placing the trauma within the context of the client's life, it helps them to make sense of their experiences and integrate them into their overall identity. ● Cognitive Restructuring - NET also involves challenging and restructuring maladaptive beliefs and assumptions that the client may have developed as a result of their traumatic experiences. This helps the client to develop a more balanced and realistic perspective on their traumatic memories, themselves, and the world around them. ● Emotional Regulation - NET also focuses on helping the client develop healthy coping skills to regulate their emotions, particularly the distressing emotions associated with the traumatic memories. This may involve relaxation techniques, emotion regulation strategies, and other skills to manage distress. ● Social Support - NET recognizes the importance of social support in the healing process. The therapist helps the client identify and strengthen their social support network, which may include family, friends, or other individuals who can provide understanding, validation, and support.

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4 Compassionate and respectful care within the therapeutic relationship is also a very important component in this process (Narrative Exposure Therapy Institute, n.d.). In order to successfully repair attachment wounds created during complex or multiple traumas, the therapeutic relationship must model values of acknowledgement, trust, honoring self-determination, and upholding the dignity of the client. This can engage a parallel process of creating a caring and connected relationship in the therapy room that can become a blueprint for the client to apply to relationships outside of treatment. NET has been used effectively in both individual and group contexts (American Psychological Association, 2017). It is a relatively low barrier form of therapeutic treatment that can be administered by both mental health professionals as well as trained non-professionals like teachers or community members (Narrative Exposure Therapy Institute, n.d.). Because of its accessibility, NET is highly compatible as a treatment modality for people in areas of active conflict and places where there is a shortage of mental health providers or difficulties in bringing providers to clients. Intended Populations, Effectiveness, and Limitations of Treatment NET is primarily meant to treat people with posttraumatic stress disorder who have experienced multiple traumatic events or complex trauma, such as survivors of childhood abuse. Most research on its efficacy centers on trials that have occurred in displaced or refugee populations, with both children and adults, living in highly insecure conditions who may have experienced social violence, sexual trauma, or physical abuse and torture ( Lely et al., 2019) . There is a significant body of research that shows that NET is effective at treating PTSD and depression symptoms across diverse, war-impacted refugee populations. Interestingly, treatment results tend to skew slightly better for older adults. This may be explained by the focus on lifespan perspective in NET which compliments the developmental concerns of people in advanced psychosocial stages, such as in Erikson’s eighth stage of Integrity vs. Despair which is also focused on lifespan integration and legacy (Cherry, 2022). NET has also been found to be effective for children, but some modification is necessary to help younger clients engage with the narrative process in a developmentally appropriate way. Since children often require more guidance in following direct instructions, using play and elements of theater and acting out, along with visual materials such as the lifeline exercise, are helpful to translate concepts into an accessible form (E. Schauer et al., 2004). One limitation of this form of therapy is the requirement that the therapist or treatment administrator be highly attuned to the needs of the client, watching for any indication during the storytelling cycle that the client is entering into a state where retraumatization could occur. The delicate balance between connecting with distressing memories and staying grounded in the present moment must be skillfully fostered by the therapist. Unlike other exposure therapies, such as Prolonged Exposure (PE), NET does not aim to desensitize the client to their experience, it aims to integrate the experience into a full lifespan awareness and place the distressing events in past time, honoring the lessons learned from those challenges. Practitioners of NET should understand this distinction and avoid using the narrative component in a confrontational or desensitizing manner (American Psychological Association, 2020).

5 References American Psychological Association (APA). (2017, May 25). Narrative Exposure Therapy (NET). Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder . Retrieved April 25, 2023, from https://www.apa.org/ptsd-guideline/treatments/narrative-exposure-therapy American Psychological Association (APA). (2020, June 1). Prolonged Exposure (PE). Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder . Retrieved April 26, 2023, from https://www.apa.org/ptsd-guideline/treatments/prolonged-exposure Cherry, K. (2022). Erikson's Stages of Development. Verywell Mind . https://www.verywellmind.com/erik-eriksons-stages-of-psychosocial-development-27957 40 Identity On the Line. (2022, March 28). How narrative exposure therapy (NET) can be adjusted for museum work - PD Dr. Maggie Schauer [Video]. YouTube. Retrieved April 25, 2023, from https://www.youtube.com/watch?v=Cyya9b98-V0 Köbach, A. (2021). Im interview mit Prof Thomas Elbert — NET Brasil. NET Brasil . https://www.netbrasil.org/news-de/te-p3yn7 Lely, J. C. G., Smid, G. E., Jongedijk, R. A., W Knipscheer, J., & Kleber, R. J. (2019). The effectiveness of narrative exposure therapy: a review, meta-analysis and meta-regression analysis. European journal of psychotraumatology , 10 (1), 1550344. https://doi.org/10.1080/20008198.2018.1550344 Narrative Exposure Therapy Institute. (n.d.). Origin, originators and method . Narrative Exposure Therapy (NET). Retrieved April 26, 2023, from https://www.net-institute.org/whatisnet Schauer, E., Neuner, F., Elbert, T., Ertl, V., Onyut, L. P., Odenwald, M., & Schauer, M. (2004). Narrative exposure therapy in children : a case study. Intervention , 2 (1), 18–32. http://kops.uni-konstanz.de/bitstream/handle/123456789/10537/Narrative_exposure_ther apy_in_children.pdf?sequence=1&isAllowed=y Schauer, M., Neuner, F., & Elbert, T. (2011). Narrative Exposure Therapy: A Short-Term treatment for traumatic stress disorders . Hogrefe Publishing. van der Kolk, B. A. & The Meadows. (2006). In terror’s grip: Healing the ravages of trauma. Cutting Edge , Spring 2006 . https://www.themeadows.com/blog/in-terror-s-grip-healing-the-ravages-of-trauma/

Narrative Exposure Therapy

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