Program Profile: Narrative Exposure Therapy (NET)

This is a psychosocial treatment program for reducing posttraumatic stress disorder (PTSD) symptoms in traumatized groups still living in dangerous situations such as in refugee camps. The program is rated Promising. The treatment group had a statistically significant improvements in PTSD symptoms and greater likelihood of leaving the refugee camp, compared with the control group. However, there were no statistically significant differences in psychological functioning or comorbid disorders.

A Promising rating implies that implementing the program may result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

A Promising rating implies that implementing the program may result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

Program Goals/Target Population

Narrative Exposure Therapy (NET) is a psychosocial treatment that aims to reduce posttraumatic stress disorder (PTSD) symptoms in traumatized refugee populations still living in dangerous situations (such as refugee camps). It attempts to reduce PTSD symptoms by habituating a patient to his or her emotional reactions to lived traumatic experiences and by creating a coherent narrative of his or her life’s experiences.

The program was developed to meet the need for psychosocial services in refugee camps. Refugee populations often demonstrate high rates of PTSD as a result of traumatic events experienced in war-affected areas. Populations in refugee camps are often impoverished and malnourished, and depend on the humanitarian aid.

Program Activities

The therapist works with a patient diagnosed with PTSD to construct a detailed chronological narrative of his or her biography. Over the course of four treatment sessions, the patient is asked to recall his or her life and include details of the traumatic events they had experienced. Frequently, this narrative initially includes fragmented reports of traumatic experience. It is the job of the therapist and patient to create a coherent narrative out of these reports. The process of construction also includes discussions to investigate current and past emotional, physiological, cognitive, and behavioral reactions to the narrative. The narrative is corrected during the course of treatment through multiple readings.

The process concludes when the patient shows evidence of habituation to the emotional reactions to these traumatic events. Patients receive a written biography at the end of treatment.

Program Theory

NET is a short-term therapeutic approach that is based on the principles of cognitive–behavioral exposure therapy and testimony therapy. In exposure therapy, the patient is asked to identify and talk repeatedly about his or her worst traumatic experience. During this conversation, the patient re-experiences the emotions experienced during the traumatic event. This can lead to the habituation of the emotional response, which, in turn, can lessen PTSD symptoms. Often, though, patients such as refugees cannot identify a single traumatic event that led to the development of testimony therapy. In testimony therapy, the patient generates a narrative of his or her life, but focuses on the details of the multiple traumatic events that he or she has experienced.

Key Personnel

Currently, the program is delivered by therapists who are doctoral-level psychologists or graduate students with experience in education and counseling. Therapists receive training in NET. To communicate with refugee populations, translators are used. In the future, developers hope that NET can be operationalized so that it can be delivered, at a lower cost, by local staff without any psychosocial educational background.

Study

Neuner and colleagues (2004) used a randomized control design to assess the effectiveness of Narrative Exposure Therapy (NET) in reducing symptoms of posttraumatic stress disorder (PTSD) in refugee populations, compared to standard treatment. Seventy-seven refugees were identified in a hut-to-hut survey of Sudanese refugees in the Ugandan refugee settlement in Imvepi. During an initial interview, 43 presented with PTSD, according to criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (or DSM–IV). None of these individuals were excluded due to symptoms of mental retardation or psychosis. The 43 individuals were randomized into three groups:

1. Psychoeducation: This group (n = 12) served as the control group and received one session, during which participants received an explanation of the nature of the symptoms caused by traumatic experiences and a demonstration that these responses are normal. All participants received this information.
2. Supportive Counseling with Psychoeducation (SC): This group (n = 14) received four sessions of supportive counseling, which included the information from the psychoeducation session. The goal of SC was to strengthen individual, social, and cultural resources for the patient. The therapy included discussions of current interpersonal problems, personal decisions, and plans/hopes for the future. The sessions included a problem-solving approach that was developed for trauma counseling in Africa. Talk about past traumatic events was not permitted. Two participants did not complete treatment.
3. NET: This group (n = 17) received 4 sessions over the course of 2 weeks, each of which lasted 90 to 120 minutes. The information from the psychoeducation session was integrated into these sessions. All participants completed treatment.

The CrimeSolutions review of this study focused on the differences between the NET treatment group and the psychoeducation control group.

Measures were taken at baseline, during initial interviews, and again at 3 or 4 weeks after first interview, at 4 months posttreatment, and at 12 months posttreatment. The initial interviews were conducted by a local interviewer and then an expert interviewer. Instruments used for data collection included

• The PTSD portion of the Composite International Diagnostic Interview (or CIDI), which was used to assess respondents for a DSM-IV diagnosis of PTSD.
• The Posttramuatic Stress Diagnostic Scale (or PDS), which measured PTSD symptom frequency and severity.
• Demography of Forced Migration Questionnaire, for data on demography, health, and traumatic experiences.
• Self-Reporting Questionnaire 20 (SRQ–20), for data on comorbid symptoms of anxiety and depression. A patient score of 10 or above on the SRQ–20 indicated that the individual was suffering from severe mental health problems.
• Medical Outcome Study Self-Report Form, for psychological functioning.

Those people in the refugee community who had worked on another epidemiological survey and had received training on administering some of the instruments through that earlier work were recruited as research assistants. Therapists were doctoral-level psychologists or graduate students with experience in education and counseling who had received training in NET. Translators were used. Fidelity of implementation was monitored through counselor self-report and through observation.

Analyses used an intent-to-treat approach. There were no systematic group differences in any of the sociodemographic variables. Repeated measures analyses of variance (or ANOVAs) were conducted to control for different baseline measures. To control for possible confounding effects of further traumas, the number of traumatic events at 1 year post treatment was entered as a covariate. No subgroup analyses were conducted.

These sources were used in the development of the program profile:

These sources were used in the development of the program profile:

Schauer, Margarete, Frank Neuner, and Thomas Elbert. 2005. Narrative Exposure Therapy (NET). A Short-Term Intervention for Traumatic Stress Disorders after War, Terror, or Torture. Seattle, Wash.: Hogrefe.