Narrative Exposure Therapy (NET)

Core Components

Narrative Exposure Therapy (NET) is an individualised, evidence-based intervention designed to treat people with PTSD and trauma disorders associated with multiple and complex trauma histories, e.g. sexual crimes, organised violence and war (including genocide survivors, child soldiers, refugees and asylum seekers). By applying similar principles to cognitive behavioural therapy, exposure therapy, and testimony therapy, NET aims to alleviate the emotional, cognitive and behavioural symptoms associated with trauma(s). It can be delivered to children, adolescents and adults.  

At its core, this manualised intervention works on the premise that non-optimal encoding of trauma memories following trauma event(s) is a consequence of physiological alarm responses. When individuals with PTSD are exposed to the trauma trigger, ‘hot’ memories for the event (including sensory information, cognitive patterns, emotions and physiological responses) are involuntarily brought to the fore without linkage to the ‘cold’ memories (i.e. context, facts) associated with the event. This can result in the re-experiencing of the trauma in the present, and adoption of avoidant behaviours.  NET therefore aims to correct dysfunctional autobiographical memories through detailed reliving of the trauma event and reconnection of ‘hot’ and ‘cold’ memories. This is done with understanding of the wider context of the events(s) and the interpretation of the event(s). Furthermore, NET aims to inhibit the fear responses associated with the trauma memory through relational re-living that occurs during therapy. 

NET is typically delivered in 8-10 sessions (although may include between 4 and 20 processing sessions). Sessions are delivered at least once weekly, each lasting about 90-120 minutes. NET consists of four parts: 

 1) Diagnostic interview and psychoeducation - involves discussion of brain model, fear networks, therapy plans, and dangers of avoidance 

2) Laying out the Lifeline is a highly individualised process that involves rolling out a piece of string/ ribbon with one end indicating time of birth, and the rolled-up end indicating the time yet to come. Stones and flowers, which represent negative/traumatic and positive events (respectively), are placed in chronological order along the rope/ ribbon. Candles can also be used to mark loved ones who have died. In the forensic version of NET (FORNET), sticks are used to represent acts of violence perpetrated by the client. This helps map out a lifeline, providing an overview of the person’s life to date 

3) Processing sessions – involve detailed exploration of the events within the lifeline. 

 Particular focus is on the stones (i.e. traumatic events) associated with the PTSD symptoms, with the aim of actively linking the ‘hot’ memories with the ‘cold’ memories, within the context of the event, and facilitating cognitive restructuring of the trauma narrative.  At least one flower (ie. positive event or relationship) is also processed to support improved mood and sense of self.  A detailed narrative of this is subsequently written by the therapist and read out in the next session to ensure accuracy of the details therein. Chronological processing of each event is carried out, until the all the events in the lifeline are processed where time allows, or selected events where prioritisation is necessary 

4) Final session rituals- involves re-reading the written narrative; signing off the narrative; and discussing hopes for the future.   

Narratives from survivors of complex traumas (e.g., associated with atrocities committed by single or multiple perpetrators) can help survivors overcome distressing feelings associated with the trauma and empower them to advocate for their human rights. With consent, these narratives can be used as evidence in prosecution of human rights violations. 

Fidelity 

NICE includes Narrative Exposure Therapy (NET) as one of the interventions within the trauma focused CBT class. NICE recommends that interventions within this class should be delivered by trained practitioner(s), typically over 8-12 sessions (or more if clinically indicated). These interventions should be delivered as per validated manual, and the stipulated content and structure should be adhered to ensure consistency in delivery. 

Fidelity in NET delivery can be assessed through case discussions during supervisory meetings, and review of recorded sessions. 

Modifiable Components  

NET manual is available in multiple languages including Dutch, English, French, Italian, Japanese, Korean, and Slovak. NET is available as Narrative exposure therapy (NET) for forensic offender rehabilitation (FORNET), an adapted version of NET that specifically addresses past violent acts, and future behaviours. NET is also available as KIDNET, a developmentally appropriate version for children and adolescents but the evidence for this is still under-development/doesn’t reach threshold for recommendation at present. An adapted three- session version  of NET (brief NET) has been associated with improvement in PTSD symptoms https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4080404/. NET can be delivered in several settings including in-patient psychiatric unit, out-patient clinic setting, and community settings https://www.frontiersin.org/articles/10.3389/fpsyt.2020.00019/full. It has also been adapted for remote delivery as eNET.

NET was developed by VIVO International, based in Germany and training is offered through the NET institute in order to ensure treatment fidelity.  Training can be booked online through Narrative Exposure Therapy Institute.  

Support for Organisation / Practice 

There is a treatment manual which is freely available.  Specialist supervision for NET is not required, although the usual requirements for supervision of specialist psychological practice must be adhered to as outlined in the Matrix. There is no formalised system of advanced training or supervision.  Experienced NET practitioners who support training usually offer post-training support and supervision/consultation. 

Implementation Support 

There is  no formal implementation support available in Scotland however, there are a few trained practitioners with a specialist interest and expertise and remote support is available through the NET Institute. 

Start-up Costs 

Training in this intervention is not currently provided by NES/within University programmes.  Services can commission training through The NET Institute and costs will apply. 

Building Staff Competency 

Qualifications Required 

In the UK, Narrative Exposure Therapy (NET) can be delivered by mental health and allied health practitioners with psychological therapy training and experience of working with trauma. Practitioners delivering NET must be empathic, encouraging, should actively listen and show genuine interest in the individual and their autobiographic memory elaboration.   

Training Requirements 

Practitioners with a mental health background who have training in psychological therapies and experience of working with trauma can attend a 3-day NET training programme prior to delivering NET.   This is an intensive programme which covers both theory and supervised practice of implementing NET techniques. 

However, there have been trials of NET delivered by lay people in conflict context such as Northern Uganda.  Non-professionals are required to attend a much more extensive training prior to delivering NET and this is not available within Scotland. 

Supervision Requirements 

 It is recommended practice in Scotland that this psychological therapy is conducted under regular supervision with a practitioner who has expertise in a) the therapy b) the clinical area and c) has completed training in supervision of psychological therapies and interventions (further information: https://www.nes.scot.nhs.uk/our-work/supervision-of-psychological-therapies-and-intervention/)

Evidence of clinical effectiveness for Narrative Exposure Therapy (NET) and other interventions classed as CBT with trauma focus have been explicitly detailed in the National Institute for Health and Care Excellence (NICE) evidence reviews for psychological, psychosocial and other non-pharmacological interventions for the prevention and treatment of PTSD in adults. 

Theory of Change  

Narrative Exposure Therapy (NET) is based on emotional processing theory which posits that PTSD emerges from the development of a fear network in memory of the traumatic events. The large number of strongly interconnected elements (e.g., cognitive, sensory, emotional and physiological) within this fear network suggests that activation of one of the elements within the fear network would set-off the entire network. This in turn elicits avoidance and escape behaviours as it pertains to elements within the fear network and cues associated with these elements. NET therefore aims to inhibit these fear responses by altering elements within the fear network, through activation of the trauma memory, whilst  bringing attention to the current context of the trauma narrative. 

Research Design & Number of Studies 

NICE’s evidence review for Narrative Exposure Therapy (NET) was carried out within the wider evidence review for trauma-focused CBT interventions. Twenty-one RCTs and eighty-eight RCTs of trauma-focused CBT interventions for the prevention and treatment of PTSD in adults (respectively) were included in meta-analyses. Evidence of effectiveness of all interventions within this class (including NET) were combined and evaluated in meta-analyses, as they apply the same approach, and their efficacies are expected to be equivalent. The observed outcomes have been summarised below. Complete information on studies included in the meta-analyses, and detailed results from the meta-analyses can be found within the NICE guideline evidence reviews 2018.   

Values 

Narrative Exposure Therapy (NET) is a manualised, evidence-based intervention designed to treat people with PTSD and other trauma disorders. It follows similar  principles to exposure therapy, and testimony therapy while emphasising the importance of empathic attunement using a specific exposure style that aims to treat all trauma across the lifespan. NET can be delivered to children, adolescents, adults and people with a history of committing offences 

• Do the target patients, basic principles, and the underlying mental health condition addressed by the intervention align with the requirements of your organisation?

Priorities 

Narrative Exposure Therapy (NET) is an individualised, psychological intervention specifically designed for trauma disorders associated with multiple and complex trauma histories, e.g. sexual crimes, organised violence and war (including refugees, asylum seekers, genocide survivors, child soldiers). NET aims to alleviate the emotional, cognitive and behavioural symptoms associated with trauma(s) by correcting dysfunctional autobiographical memories and inhibiting the fear responses associated with the trauma memory.  

• Is your service looking to deliver an individualised intervention for the treatment of PTSD or other trauma related disorders?
• Will people using your service possibly have multiple and complex trauma histories (e.g. child soldiers, refugees, genocide survivors)?

Existing Initiatives

• Does your service deliver other interventions for the treatment of PTSD?
• Are existing initiatives applicable to persons with multiple and complex trauma histories?
• Do existing initiatives fit current and anticipated requirements?

Workforce

Narrative Exposure Therapy (NET) can be delivered by trained psychological therapists  Practitioners must attend NET training prior to delivering the intervention. NET is typically delivered to people using services in 8-10 sessions, although more may be necessary where there high levels of severe and extensive trauma. Sessions are offered at least once weekly, and last about 90-120 minutes. 

• What qualifications will practitioners within your service have, prior to delivering NET?
• Are these practitioners available and interested in learning and delivering NET?
• Can your service support the time commitment required for practitioner training, supervision, and intervention delivery?

Technology Support

Narrative Exposure Therapy (NET) can be delivered without access to technology, but access to methods of recording sessions to assess treatment adherence will be useful.  NET has been adapted (eNET) for remote delivery. 

• Can your practitioners access technology to record sessions for supervision?

Administrative Support

NET can be delivered in several settings including in-patient psychiatric unit, out-patient clinic setting and community settings. It is typically delivered in 8-10 sessions, with sessions offered at least once weekly, and lasting about 90-120 minutes. Administrative support is needed to manage therapy appointments and collate and input outcome measures. People using services can include refugees, asylum seekers, genocide survivors and child soldiers. 

• In what setting will the NET intervention be delivered?
• Does your service have a venue within the chosen setting(s) to deliver the NET sessions?
• Can your service provide the services of a translator for non-English speaking persons using the service?
• Can administrative supports needed to deliver the NET interventions be provided?

Financial Support

There are no start-up costs associated with training provided within university training programmes (if training through an NHS place) or by NES. However, there is no current routine availability of this training in NHS Scotland. Costs apply when training is provided by private organisations.

• Can your organisation financially support implementation costs for services accessed outside NES?

Comparable Population

Comparable Population  

Narrative Exposure Therapy (NET) is an individualised, psychological intervention specifically designed for trauma disorders associated with multiple and complex trauma histories, e.g. sexual crimes, organised violence, and war (including refugees, asylum seekers, genocide survivors, child soldiers). Evidence of effectiveness come from twenty-one RCTs and eighty-eight RCTs of trauma-focused CBT interventions for the prevention and treatment of PTSD in adults (respectively). Evidence of effectiveness of all interventions within the trauma-focused CBT class (including NET) were combined and evaluated in meta-analyses. Separate evidence showing the effectiveness of NET alone has not been reported. 

• Is this comparable to the population your service would like to serve?

Desired Outcome

Cognitive Behavioural Therapy with trauma focused interventions have been shown to effectively reduce acute stress disorder diagnosis, PTSD diagnosis, and symptoms of comorbidities associated with PTSD (including depression and anxiety) following early initiation of intervention (≤1 month). These interventions have also been shown to reduce PTSD symptoms, reduce symptoms of comorbidities associated with PTSD (including depression and anxiety), and reverse PTSD diagnosis following early (1-3 months) and delayed treatment (≤ 3months).  Effects have been sustained at follow-up. 

• Is delivering trauma-focused psychological therapy for the treatment of PTSD and other trauma disorders in children, adolescents, and adults a priority for your organisation?
• Does your organisation have other initiatives in place that effectively and efficiency achieve the above outcomes?