Narrative Exposure Therapy

Narrative Exposure Therapy and PTSD

Among the techniques used to support people with PTSD is Narrative Exposure Therapy (NET). It can be a group work option or used for one-to-one counselling and support, as a short term intervention.

NET is particularly relevant to help individuals who have faced multiple or complex traumas (sometimes referred to as C-PTSD), and also children who have experienced severe trauma (KidNET).

It links to trauma-focused cognitive behaviour therapy (TF-CBT). In 2018, the National Institute for Health and Care Excellence (NICE) recommended NET as a method of treating adults with PTSD, using studies that were focused on TF-CBT interventions.

However, TF-CBT and NET do differ. Particularly as Narrative Exposure Therapy works along a lifeline, exploring experiences in chronological order.

Origins of Narrative Exposure Therapy

The concept of narrative exposure therapy was developed by Maggie Schauer, Frank Neuner, and Thomas Elbert in the early 2000s. Their work has been backed up by field studies and can be found in the manual ‘Narrative Exposure Therapy: A Short-Term Treatment for Traumatic Stress Disorders’.

The authors say: “For victims, regaining access to their biographies and communicating their history to others can empower them to stand up for their rights as victims of violence and overcome feelings of anger, hopelessness, and powerlessness.”

The therapy fundamentally works on the premise that trauma creates an alarm response. The amygdala (an almond-shaped part of the brain that deals with emotional associations and responses) attaches negative, long-lasting links to the emotional, cognitive, sensory, and physiological experience.

The person with PTSD may then suffer flashbacks and avoid anything that triggers that memory. They may suffer long term feelings of anger, grief, distrust, loneliness, confusion, low self-esteem, and shame. Their faith in others – especially – caregivers will have been violated.

This can lead to PTSD but also unhealthy coping strategies including addictions, compulsions, phobias and self-harm.

The basic theory behind Narrative Exposure Therapy is that by talking through traumatic events in chronological order, you can slowly and methodically repair negative associations and responses (more on this below).

It’s most commonly used to treat refugees – particularly children – who have lived in war zones. Or for anyone who feels an ‘outsider’, and who is resisting other forms of help. According to the team behind its development: “As a result of this distress and acquired survival-oriented patterns of interacting with others, professionals may feel challenged by complex trauma survivors’ dependence, aggression, self-destructiveness, and distrust.”

How is NET delivered?

The therapist would ask for a detailed recounting of the trauma or traumas. This does not begin at the worst event or experience, but the earliest.

Symbols are usually used to guide the individual through a step-by-step account of what happened to them. This is often stones to mark a particularly negative time, and flowers to donate happier experiences. The size of each can be representative of the level of emotion.

The therapist records this ‘journey’ and makes sure that each retelling contains all relevant details. This also forms the basis of questions to help participants fill gaps.

Each time the narrative is explored, the person is encouraged to understand and control their responses. This is sometimes referred to as taking a ‘hot’ memory full of emotion and transferring it into a ‘cold’ memory with greater logic attached.

The individual is supported to develop a stronger sense of self-worth and to acknowledge their own value and human rights in the context of their lived experience. Letting go of any sense of guilt. The therapist uses empathy, active listening, and positive affirmation to support the process. Anchors such as time and place keep emotional and physical responses in the past, so they don’t lose the sense of the present and their place of safety.

One of the reasons NET is used for people who have experienced multiple or complex traumas is that it enables them to explore their entire lived experience and the impact that has on their identity. In some cases, the patient is given a written copy of their narration, to help them to continue to process and contextualise the trauma, reducing the negative associations and reactions.

Can narrative exposure therapy be harmful?

Any type of exposure therapy can have its limitations. The problem is that a detailed reliving of trauma can be excruciating and potentially escalate negative emotions and responses for some people with PTSD. Also, among the symptoms of PTSD are re-experiencing and avoidance. If a person with PTSD is aware that treatment will expose them repeatedly to difficult memories, it can make them reluctant to engage.

This is why organisations like the American Physiological Association ‘conditionally’ recommend its use.

It is imperative that narrative exposure therapy is only used by trained professionals in a clinical environment, with the informed consent of individuals with PTSD.

NICE guidance updated in 2018 recommends the use of trauma focused psychological treatments for Post Traumatic Stress Disorder in adults, specifically the use of Eye Movement Desensitisation Reprocessing (EMDR) and trauma focused cognitive behavioural therapy (CBT).

Please remember, these aren’t meant to be medical recommendations, but they’re tactics that have worked for others and might work for you, too. Be sure to work with a professional to find the best methods for you.

Photo by Valentin Salja on Unsplash

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