The Hexagon: An Exploration Tool
The Hexagon can be used as a planning tool to guide selection and evaluate potential programs and practice for use.
Usability - Rating: 4
4 - Usable
The intervention has operationalised principles and values, core components that are measurable and observable, tools and resources to measure fidelity, and identified modifiable components
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.
Supports - Rating: 2
2 - Minimally Supported
Limited resources are available beyond a curriculum or once-off training
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 - Rating: 4 - 5
4 - Evidence
The intervention has demonstrated effectiveness with one rigorous, external research study with the focus population and a control group.
5 - High Evidence
The intervention has demonstrated evidence of effectiveness based on at least two rigorous, external research studies with the focus population and control groups, and has demonstrated sustained effects at least one year post treatment.
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.
Children and Young People - Rating: 4
Children and Young People: Outcomes achieved
There have been 9 studies evaluating KIDNET including 4 RCTs comparing KIDNET to active controls with mixed results. The samples of all studies were asylum seekers, refugees, or living in conflict zones. Compared to active control groups, involving for example emotional freedom techniques in Iraq, meditation relaxation in Sri Lanka, and TAUs in Finland and South Korea, the KIDNET results are mixed. KIDNET showed an advantage in some studies in longer term follow-up compared to active controls.
Adults - Rating: 5
Adults: Outcomes Achieved
A systematic review in 2020 (Siehl, Robjant & Crombach identified In total, 28 RCTs have been conducted with NET, KIDNET and FORNET. In a total of 56 studies from 30 countries comparing 1370 participants treated with NET to 1055 controls, the review found large between group effect sizes regarding the reduction of PTSD symptoms in favour of NET. Analyses of RCTs with active controls yielded small to medium effect sizes in the short-term, and large effect sizes in the long-term.
Need
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.
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.
1 - Does Not Meet Need
The intervention has not demonstrated meeting need for the identified population
2 - Minimally Meets Need
The intervention has demonstrated meeting need for the identified population through practice experience; data has not been analysed for specific subpopulations
3 - Somewhat Meets Need
The intervention has demonstrated meeting need for the identified population through less rigorous research design with a comparable population; data has not been analysed for specific subpopulations
4 - Meets Need
The intervention has demonstrated meeting need for the identified population through rigorous research with a comparable population; data has not been analysed for specific subpopulations
5 - Strongly Meets Need
The intervention has demonstrated meeting the need for the identified population through rigorous research with a comparable population; data demonstrates the intervention meets the need of specific subpopulations
Fit
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
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.
Existing Initiatives
1 - Does Not Fit
The intervention does not fit with the priorities of the implementing site or local community values
2 - Minimal Fit
The intervention fits with some of the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
3 - Somewhat Fit
The intervention fits with the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
4 - Fit
The intervention fits with the priorities of the implementing site and local community values; however, the values of culturally and linguistically specific population have not been assessed for fit
5 - Strong Fit
The intervention fits with the priorities of the implementing site; local community values, including the values of culturally and linguistically specific populations; and other existing initiatives
Capacity
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.
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.
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.
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.
1 - No Capacity
The implementing site adopting this intervention does not have the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
2 - Minimal Capacity
The implementing site adopting this intervention has minimal capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
3 - Some Capacity
The implementing site adopting this intervention has some of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
4 - Adequate Capacity
The implementing site adopting this intervention has most of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
5 - Strong Capacity
Implementing site adopting this intervention has a qualified workforce and all of the financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
