Brief concepts on Narrative
Exposure Therapy
Introduction to trauma
and NET
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What is Trauma?
Unbearable and intolerable attack perpetrated
towards the self (the body, the mind and the
brain). (Van der Kolk: The body Keeps the
Score)
Experience(s) that destroy the human kernel.
(Schauer et al: Narrative Exposure Therapy)
What can be traumatic?
DSM V: Experiencing, witnessing, learning
and repetitive work related exposure to life
threatening events.
How can people be traumatized?
Organized vs. unorganized
Type I events vs. Type events II
How do traumatized people
feel/present?
Intrusive symptoms
Avoidance (active or passive)
Arousal symptoms
Negative cognition and mood
The dialectics of trauma
Avoidance vs. Repetition compulsion
Hyperarousal vs. Hypoarousal
Intrusive memories vs. having no recollection
To deny vs. to tell
Any other presentation?
Reorganization of perception
Stuck in trauma
Making sense of suffering
Inescapable shock
Speechless horror
Psychosocial sequelae of
trauma
As syphilis was to medicine,
trauma is to psychiatry.
Why do people respond
differently?
Vulnerability and Resilience determined by:
Pretraumatic factors
Trauma related factors
Post traumatic factors
With severe traumatic exposure,
no body is immune.
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How do people react to
stress/trauma?
Freeze
Fight – Flight
Fright
Flag
Faint
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The uproar – PTSD vs. The shutdown -
PTSD
PTSD and Memory
People are not fully aware that what they are
experiencing through flashback is active
memory arising from past experience.
The memory of the traumatic event does not
seem to be fixed in the context of time and
space in which it actually occurred.
Feel the experience, but prevented from
communicating coherently.
Schematic representation of
Memory
Schematic representation of
Memory
TRAUMATIC
MEMORY
It sets up a
stream of
thoughts
and gives
the event
personal
meaning.
It
evalua
tes
the
emoti
It evaluates unrelated onal
events, compare it signifi
with previously stored canc
information and e.
determines how they
are associated.
It sets up a
stream of
thoughts
and gives
the event
personal
meaning.
It
evalua
tes
the
emoti
It evaluates unrelated onal
events, compare it signifi
with previously stored canc
information and e.
determines how they
are associated.
It sets up a
stream of
thoughts
and gives
the event
personal
meaning.
Traumatic
memory
Speechless
terror
It
evalua
tes
the
emoti
It evaluates unrelated onal
events, compare it signifi
with previously stored canc
information and e.
determines how they
are associated.
What determines how/where to
save?
Rational brain
Emotional Brain
Reptilian Brain
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So what can we do?
There are fundamentally three avenues of
reverse these impacts of trauma on brain,
body and mind
Medication
Bottom up
Top down
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Narrative Exposure Therapy
… “the ability to create symbolic representations
of terrifying experiences promotes the taming of
terror and de-somatization of traumatic
memories.”
(Van der Kolk 1994)
Raw experience + Meaning = Narration
A naturally occurring conflict exists between
wanting to deny the horrible events and
feeling the urge to scream out the extent of
the atrocities.
NET works at the level of the individual by
encouraging the telling of the trauma story
and by reliving the past traumatic sceneries
with in an imaginative exposure.
Habituation and reorganization of memory
through narratives.
All the positives!
Community reconcilliation
Roots in testimony therapy (Chile, Pinochet regime
1980’s)
Combines exposure with retelling
Lifeline: Flowers and stones, emphasizing resilience
Organized sequentially, able to review more
than one trauma
Emphasis on life story, not just trauma
NET: INTERGRATES ‘HOT’ PROCEDURAL MEMORIES
INTO ‘COOL’ EXPLICIT MEMORY
=AUTOBIOGRAPHICAL NARRATIVE
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Selected NET References
Gwozdziewycz, N and Mehl-Madrona, L. 2013. Perm J. Winter
17(1). Meta-analysis of the use of Narrative Exposure Therapy
for the effects of trauma among refugee populations.
Neuner, Frank; Onyut, Patience Lamaro; Ertl, Verena; Odenwald,
Michael; Schauer, Elisabeth; Elbert, Thomas. Treatment of
posttraumatic stress disorder by trained lay counselors in an
African refugee settlement: A randomized controlled trial. Journal
of Consulting and Clinical Psychology, Vol 76(4), Aug 2008, 686-
694.
Elbert, T., Schauer, M., Neuner, F. (2015).
Narrative Exposure Therapy (NET) – reorganizing memories of
traumatic stress, fear and violence.
In: Schnyder U., Cloitre M. (eds.), Evidence Based Treatments
for Trauma – Related Psychological Disorders: A Practical Guide
for Clinicians. Berlin, Heidelberg, New York, Tokyo: Springer.
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Bichescu, D., Neuner, F., Schauer, M., Elbert, T. (2007). Narrative Exposure
therapy of political imprisonment-related chronic posttraumatic stress disorder and
depression. Behaviour Research and Therapy , 45(9), 2212-20.
Catani, C. , Kohiladevy, M., Ruf, M., Schauer, E., Elbert, T. & Neuner, F.(2009).
Treating children traumatized by war and Tsunami: A comparison between
exposure therapy and meditation-relaxation in North-East Sri Lanka, BMC
Psychiatry, 9:22.
Catani, C. , Schauer, E., Elbert, T., Missmahl, I., Bette, J.-P., Neuner, F. (2009). W
ar trauma, child labor and family violence: Life adversities and PTSD in a sample
of school children in Kabul, Journal of Traumatic Stress, 22(3), 163-171.
Elbert T., Schauer, M. (2002). Psychological trauma: Burnt into memory. Nature
,419, 883.
Ertl, V., Pfeiffer, A., Schauer, E., Elbert T, Neuner, F. (2011). Community-
implemented trauma therapy for former child soldiers in Northern Uganda: a
randomized controlled trial. JAMA, 306(5), 503-12.
Ertl, V., Pfeiffer, A., Saile, R., Schauer, E., Elbert, T., Neuner, F. (2010). Validation
of a mental health assessment in an African conflict population. Psychol
Assessment 22(2), 318-
24.
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THE END
Important things in therapy
karpman triangle
neutrality
Patient’s pace
zone of optimal arousal
avoid persuasion
blaming perpetrator
Avoid long sessions
THE END
