Narrative Exposure Therapy

CLICK HERE TO ORDER THE BOOK ABOUT NET
Schauer, M. / Neuner, F. / Elbert, T. (2005). Narrative Exposure Therapy (NET). A Short-Term Intervention for Traumatic Stress Disorders after War, Terror, or Torture. Hogrefe & Huber.

Unaware of the consequences of psychotrauma on their mental health, survivors generally avoid to seek psychotherapeutic treatment, they are caught in an inability to express what happened. They suffer so-called 'speechless terror', frightening thoughts and memories of their ordeal and feel emotionally numb, especially towards people they were once close to.

Remembering the traumatic experience brings up painful emotions. The recollection is usually coded in a fragmented and incoherent way in autobiographic memory. In most cases it is extremely difficult for the survivors to put their experiences into words of narration, meaning, they are often unable to tell a coherent story. Most survivors of state-sponsored violence avoid talking about what happened to them. This tendency to keep silent about their past, prevents emotional processing of the events. In addition to the adverse consequences for the survivors themselves, the tendency of survivors to remain silent hinders the fight against violations of human rights and the prosecution of those who are responsible for acts of torture and genocide.

In various different settings around the world, vivo's therapists and researchers noticed, that, at the same time, most survivors do have a great need to talk about their painful experiences. It is difficult however to find careful listeners in societies, where a majority of members have suffered traumatic stress. As a consequence, vivo introduced Narrative Exposure Therapy (NET), a joint approach of treatment of survivors and documentation of human rights violations, in order to overcome the victims' and communities' imprisonment in speechlessness. The procedure is based on Testimony Therapy (as developed by Lira and Weinstein in Chile) in combination with cognitive behavioural exposure techniques. Witnesses to severe human rights violations are invited to testify their traumatic experiences. In cooperation with the therapist they can restore their autobiographic memories about those experiences. In this way fragmentary memories are transformed into a coherent narrative structure: a testimony. This practice enables the processing of painful emotions and the construction of clear contingencies of dangerous and safe conditions, generally leading to significant emotional recovery. If the survivor agrees, the documents (testimonies) that result from this therapy can directly be used for prosecution of human rights violations (see section below) or awareness raising purposes.

In rural community settings or in conflicts related emergency situations, few survivors are able to attend counseling sessions on a regular base, necessary for the application of conventional therapies. Most conventional psychological therapies require weekly or fortnightly attendance by the client, with a minimum length of 6 months for the therapy process. This is rarely possible in rural or emergency settings, where people only attend health care facilities that are in close proximity to their homes, or where people are frequently displaced or forced to move.

In contrast to conventional western psychotherapy, the Narrative Exposure Therapy (NET) procedure does usually not require more than three to four sessions that can be carried out in any silent place in a community or at the survivor's home. Of course, this short treatment does not immediately result in a complete cure of severe psychological disorder. But it can lead to a considerable relief for the survivor and can foster further emotional processing of the traumatic memories and a recollection of the collective history of the community.

At times, social scientists and political activists criticize psychosocial programs that provide counseling for survivors of state-sponsored and organized violence, in influential commentaries. These statements initiated a heated debate about the usefulness of psychological interventions in developing countries in general. vivo would like to contribute the following facts to this discussion, from its rich experience in clinical as well as field oriented research:

Problem statement 1: Psychosocial interventions do not fit the needs of survivors of war and persecution.

Our experience in vivo indicates that victims of state-sponsored violence are more likely to participate in Narrative Exposure Therapy (NET) than to seek other kinds of treatment. The reason for this is the dual meaning of NET: On the one hand, clients are given the chance to do justice through documentation and thus meaning is attached to their terrifying experiences, on the other hand clients may benefit from the consequences of careful therapeutic intervention. Thus, an explicit political orientation (based on the UN Declaration of Human Rights) of Narrative Exposure Therapy (NET) seems to be of significant advantage. International Criminal Tribunals, who have to rely on the validity of the data they get from the interviews, can profit from the completeness of a victim's report, as this determines the usefulness of a testimony for legal pursuits.

Problem statement 2: Applying western concepts of psychotherapy risks perpetuating the colonial status of the non-western mind.

One of Narrative Exposure Therapy (NET)'s main precursors, Testimony-Therapy, was invented in Chile especially for local survivors of state-sponsored violence. The procedure of NET is comprehensible for survivors from all cultures, since story telling and verbal expression is a concept shared amongst all humankind, it does not necessarily obtrude western concepts. In fact Narrative Exposure Therapy (NET) proves extremely culturally sensitive, since survivors tell their own stories, in their own fashion and ways of cultural expression, related to their own traditional and personal background and setting. vivo's studies in different countries show that the acceptance of Narrative Exposure Therapy (NET) amongst local people was extremely high.

Problem statement 3: The efficacy of trauma counseling in African countries has not yet been proven.

vivo directly aims at scientifically evaluating the efficacy of treatment interventions. Recent research shows that even in Western countries not all psychosocial interventions for trauma victims are effective some can even be harmful. Nevertheless, many psychosocial organizations implement ad-hoc treatment approaches like, i.e. supportive counseling or debriefing in war-affected countries without evaluating the potential effect or harm. A central principle of vivo is that no treatment method shall be administered without strict evaluation. Our first controlled study in Uganda demonstrated both, the applicability and the efficacy of Narrative Exposure Therapy (NET) under the harsh conditions of an African refugee settlement. Established measures for psychological morbidity and cultural sensitive measures of quality of life have been used. We could show, that one-year after treatment those survivors who had received Narrative Exposure Therapy (NET) significantly improved and were much better off (statistically significant for social, economical and emotional variables of functioning) than those who had received either supportive counseling or psycho-education. Striving for appropriate mental health care turned out to be anything but a 'luxury' service. Most survivors who, before treatment where suffering from a disorder of extreme stress, were unable to perform activities to enhance the economic and social living conditions for themselves and their families. After treatment with NET, the same persons were able to return to work, tend to their fields and reengage in social and intimate relationships. The majority of those diagnosed with PTSD who could not be reached by NET, where still suffering from overwhelming symptoms one year later, such as intrusions and nightmares, their health had deteriorated and feelings of worthlessness and suicidal ideations had increased. Their lives were characterized by hopelessness, starvation and the inability to fulfill their societal roles. The outcome of this first controlled treatment study on PTSD in an African refugee settlement is promising and shows that both, short-term treatment approaches and evaluation research are essential in any setting. And that a negatively reinforcing vicious circle can be effectively reversed through appropriate treatment interventions.

Problem statement 4: Psychosocial procedures neglect the social and political context of the violation. Essentially the concern is that "medicalization" of social problems deflects attention from national and international responsibility (Muecke, 1992).

A central goal of vivo's work is the documentation of human rights violations. The core intention in the creation of Narrative Exposure Therapy (NET) was, that psychological treatment at the same time as it intends to heal, contributes directly to the fight against torture and persecution.