The emerging evidence for Narrative Exposure Therapy: A review
Research Highlights
►Narrative Exposure Therapy (NET) is a short-term therapy for individuals who have PTSD ►Emerging evidence suggests that NET is an effective treatment for PTSD in individuals who have been traumatised by organised violence ►NET has been used to treat asylum seekers and refugees in low and middle-income as well as high-income settings and lay counsellors have been trained to deliver the therapy ►Treatment trials of KIDNET have shown its effectiveness in reducing PTSD amongst children.
Introduction
The global burden of disease as a result of armed conflict continues to rise each year and the affected individuals, predominantly in low- and middle-income countries, are a particularly challenging group to treat. This is because they often live in insecure settings that have limited access to resources and few trained professionals to manage their care. Narrative Exposure Therapy (NET) was developed with these populations in mind, it is a brief, manualised treatment for the psychological sequelae of torture and other forms of organised violence, and can be delivered by non-mental health professionals. Since its development less than a decade ago, it has been shown to have therapeutic benefits for a wide range of individuals and settings. These include successful use in both adults and children, with asylum seeker, refugee and native populations and in a number of different countries, both high and lower income. This review aims to collate all the information so far available on the therapeutic effects of NET.
The numbers of individuals fleeing war and political violence varies each year but recent estimates suggest that over 1% of the world's population, 67 million people, are currently forcibly uprooted (UNHCR, 2008). The worldwide refugee population has continued to rise over the last few decades with a tenfold increase in the numbers affected in the last decade of the twentieth century (UNHCR, 2000, UNHCR, 2008). Of note, the nature of conflict has changed, with a greater proportion of current war victims being civilians rather than combatants (Stockholm International Peace Research Institute, 2000).
A dose–response relationship between traumatic events and symptoms of post-traumatic stress disorder (PTSD) amongst civilians affected by war and organised violence has been demonstrated in many populations including amongst survivors of the Pol Pot regime (Mollica et al., 1998); in Bhutanese (Shrestha et al., 1998) and Burmese (Allden et al., 1996) refugees; in Ugandan and Sudanese nationals and Sudanese refugees (Neuner, Schauer, Karunakara, et al., 2004) and in adults living in Afghanistan (Scholte et al., 2004). Similar findings have also been found amongst asylum seekers and refugees in high-income settings, reporting stressful events in both their country of origin and whilst settling in their host country (Silove et al., 1997).
A meta-analysis investigating the mental health of refugees and other populations exposed to mass conflict and displacement across the globe found high rates of psychopathology (Steel et al., 2009). In 145 surveys (n = 64,332) the overall weighted prevalence of PTSD was 30.6%. In another meta-analysis investigating pre- and post-displacement factors associated with mental health difficulties (Porter & Haslam, 2005), refugees (including internally and externally displaced individuals) had poorer mental health than non-refugee controls, even though some comparison groups had experienced war and its associated violence.
The three core symptoms of PTSD are firstly the re-experiencing of intrusive vivid memories of traumatic events both during sleep and in the day, when the individual often has a sense they are re-living the event. Secondly, the active avoidance of anything that may trigger these memories, with associated emotional numbing, derealisation and depersonalisation. The final symptom is persistent hyperarousal and an exaggerated startle response, reflecting the readiness of the body's fight or flight response.
In a review by Brewin and Holmes (2003) three main theories of PTSD were identified as having the most explanatory power for the current empirical findings and observed clinical symptoms in patients. These are 1) emotional processing theory (Foa & Rathbaum, 1998) 2) dual representation theory (Brewin, Dalgleish, & Joseph, 1996) and 3) Ehlers and Clark's cognitive model (Ehlers, Clark, Hackmann, McManus, & Fennell, 2005). There are a number of similarities between the models which all emphasise maladaptive processing of traumatic events. They also explain how a fragmented autobiographical memory, lacking in contextual information, results in a subjective sense of current threat, as the traumatic event is indistinguishable from the present context. The three models also construe that the intrusive re-living phenomena associated with PTSD occurs through activation of the entire memory of the traumatic event following exposure to one or more internal or external cues (although they differ in their conceptualisation of how this occurs).
Whilst these models account for PTSD resulting from single event trauma, the relevance for complex PTSD that can follow multiple traumatic events is less clear (Green et al., 2000). Some authors have suggested that PTSD symptoms following multiple or chronic traumatic events, particularly those originating from organised violence or torture, is sufficiently different to warrant further diagnostic refinement (Herman, 1992, Silove, 1996, Silove, 1999). There is evidence of lasting neurobiological differences amongst survivors of severe organised violence including torture (Elbert, Rockstroh, Schauer, & Neuner, 2006). Conversely, some have argued that PTSD itself is an unhelpful diagnosis which may not be culturally relevant to those who have experienced trauma associated with war and organised violence, where an understanding of the social and political context is important (Bracken et al., 1995, Summerfield, 2001). Other authors have pointed to the accruing evidence of biochemical, neuroanatomical and phenomenological characteristics differentiating PTSD from other psychiatric conditions. This is particularly true of memory distortions and other cognitive abnormalities associated with PTSD (Mezey & Robbins, 2001).
One of the clearest benefits of the conceptualisation of psychological models of PTSD has been the development of successful psychological treatments. This is most evident in the clinically effective cognitive–behavioural treatment protocol devised by Ehlers et al. (2005). There is good evidence for the efficacy of Trauma Focused CBT (TFCBT) and Eye Movement Desensitisation and Reprocessing (EMDR) for the treatment of PTSD, and these are both recommended in the National Institute for Health and Clinical Excellence (NICE) guidance for treating PTSD (NICE, 2005).
In a review and meta-analysis of 38 randomised controlled trials undertaken as part of the preparation for these guidelines, Bisson et al. (2007) demonstrated the superiority of TFCBT and EMDR over other psychological approaches. Two other approaches: stress management and group CBT, were also found to be effective in reducing PTSD. Exposure to the memories of the traumatic event is a core feature of both EMDR and TFCBT, and therapies that did not focus on the trauma itself but instead focused on current or historical problems were not as effective in reducing PTSD. Ehlers et al. (2010) show that, in seven out of eight meta-analyses or systemic reviews, trauma-focused psychological treatments are most effective in treating PTSD although one meta-analysis showed that all treatments are equally effective (Benish, Imel, & Wampold, 2008). Few of the studies were conducted on individuals who had experienced multiple, severe events in the context of war and organised violence and the two studies involving Vietnam War veterans, had less favourable outcomes. The authors suggest that this population are more difficult to treat. The reason for this is unclear, but it is feasible that the severity and multiplicity of traumatic incidents occurring in war contexts sets this group apart (Silove, 1999). Other authors have highlighted the necessity of continuing to develop and improve existing treatments as well as to be innovative in creating new treatments to reduce drop out rates and treatment failures (Cukor, Spitalnick, Difede, Rizzo, & Rothbaum, 2009).
A further therapy: testimony therapy, has been developed as a type of therapy that places the trauma within the cultural socio-political context in which it occurred (Cienfuegos & Monelli, 1983). To our knowledge there are no published trials comparing this therapy with other trauma-focused treatments.
In general there is a paucity of data available regarding effective treatments for trauma-related sequelae from lower-income settings, yet the majority of refugees reside in such areas (approximately 9 million of the world's 13 million refugees) (UNHCR, 2008). Research has shown that psychological treatments are effective in reducing PTSD in high-income countries, although the evidence for the effectiveness of these treatments in reducing PTSD in those who have experienced multiple traumatic events of a severe and chronic nature is less clear. Western psychological models which have been shown to be effective have included an element of exposure, whilst other therapies designed for victims of organised violence have stressed the importance of giving testimony (Cienfuegos & Monelli, 1983). The NICE guidelines refer to the limited data for this specific group and mention the efficacy data that had recently emerged for Narrative Exposure Therapy (Neuner, Schauer, Klaschik, Karunakara, & Elbert, 2004) as ‘encouraging’.
Section snippets
Theoretical background
NET is a new treatment that has been devised specifically for the victims of organised violence, incorporating many of the exposure elements of existing models with an additional focus of clearly documenting the atrocities endured (Schauer, Neuner, & Elbert, 2005). Originally devised to be administered in refugee camps with the aim that it could meet the pragmatic demands of providing care in emergency settings by being delivered by non-mental health professionals in a short period of time, it
Methods
There have been a number of trials in adult populations, both published (Bichescu et al., 2007, Halvorsen & Stenmark, 2010, Neuner, Catani, et al., 2008, Neuner, Schauer, Klaschik, et al., 2004, Neuner et al., 2010, Schaal et al., 2009) and unpublished (Adenauer et al., in preparation, Ertl et al., 2008, Hensel-Dittman, et al. in preparation, Jacob et al., 2010, Stenmark et al., in preparation). The studies have taken place in both low- and middle-income as well as high-income settings, and on
Discussion
This review summarises the evidence currently available on NET, an important new treatment for those with PTSD following multiple traumatic events such as those occurring in war or as a result of organised violence. It summarises data from 16 trials, six of which are on children and adolescents and eleven are conducted in low- and middle-income settings. Approximately 176 adults and 40 children and adolescents were treated with NET in the published studies. There are a number of interesting
Disclosure statement
MF was a co-applicant and KR was funded by a European Union Refugee Fund (ERF) – Community Actions Project 2007: Multi-Centre NETwork Strengthening Grant.
Acknowledgements
We are grateful to the study authors who provided invaluable further information.
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