Narrative Exposure Therapy for Post-Traumatic Stress Disorder

Abstract

Narrative Exposure Therapy (NET) is a relatively novice treatment that may be beneficial for use with individuals who suffer from Post-traumatic Stress Disorder (PTSD). The aim of this review was to explore the mechanism, evidence-base and effectiveness of NET in remediating PTSD symptoms. A literature search was carried out using Medline, PsycINFO, EMBASE and The Cochrane Central Register of Controlled Trials (CENTRAL). Reference lists of papers, review articles and grey literature were also hand searched. Findings were presented in a narrative review.
The emerging research on NET presents it as a potentially effective and accessible treatment of PTSD symptoms though careful consideration of cultural issues must be made prior to and during application. Current research on NET provides evidence on its effectiveness especially with refugee populations for whom it was initially intended. It also has additional attractive characteristics such as its accessibility and cultural consideration. However methodological limitations of existing studies, in particular the small sample sizes, have to be noted.

Full text

Narrative Exposure Therapy for Post-Traumatic Stress Disorder
Paulann Grech1 and Reuben Grech2*
1Lecturer of Mental Health, University of Malta, Malta
2Department of Medical Imaging, Mater Dei Hospital, Malta
*Corresponding author: Reuben Grech, Department of Medical Imaging, Mater Dei Hospital, Malta, Tel: 00356 79298235; Fax: 00982155613191; E-mail:
reubengrech@yahoo.com
Received date: June 21, 2018; Accepted date: July 11, 2018; Published date: July 18, 2018
Copyright: ©2018 Paulann Grech, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Abstract
Narrative Exposure Therapy (NET) is a relatively novice treatment that may be beneficial for use with individuals
who suffer from Post-traumatic Stress Disorder (PTSD). The aim of this review was to explore the mechanism,
evidence-base and effectiveness of NET in remediating PTSD symptoms. A literature search was carried out using
Medline, PsycINFO, EMBASE and The Cochrane Central Register of Controlled Trials (CENTRAL). Reference lists
of papers, review articles and grey literature were also hand searched. Findings were presented in a narrative
review.
The emerging research on NET presents it as a potentially effective and accessible treatment of PTSD symptoms
though careful consideration of cultural issues must be made prior to and during application. Current research on
NET provides evidence on its effectiveness especially with refugee populations for whom it was initially intended. It
also has additional attractive characteristics such as its accessibility and cultural consideration. However
methodological limitations of existing studies, in particular the small sample sizes, have to be noted.
Keywords: Stress disorders; Post-traumatic; Narrative therapy;
erapeutics; Recovery of function
Introduction
PTSD is a highly prevalent disorder that is typically related to
traumatic events [1]. It originated from the Vietnam War as
experienced by soldiers and found its way in the Diagnostic and
Statistical Manual of Mental Disorders (DSM) in 1980. Whilst a
number of treatment options, in particular psychotherapeutic ones
have been developed [2], evidence-based guidelines for the diagnosis
and management of this disorder have been issued by the National
Institute for Health and Clinical Excellence [3] and the World Health
Organization [4].
Since its conception, the clinical diagnosis of PTSD has broadened
so that it is also applicable to other traumatic experiences not
necessarily resulting from war [5]. Although symptoms usually appear
during the rst month following the traumatic event, in a few
individuals, delays of months and even years have been reported prior
to the onset of symptoms [3].
In the United States, the prevalence of PTSD is around 8% [6].
However in specic populations such as refugees, the rate of PTSD is
much higher [7] and the attributed risk has been shown to be as higher
as 10 times more than the general population [7]. Overall, the
incidence of PTSD has been found to be between 8.1%-13 % for males
and 20.4-30.2% for females [6,8].
Although trauma can have various psychological eects on an
individual, not all responses can be classied as PTSD as a number of
conditions have to be met. Several debates have evolved around the
denition of a traumatic stressor and these led to the modication of
the meaning. Whereas initially a major stressor was understood as
being a catastrophic event that is not usually experienced in the life of
a human being, the contemporary meaning relates to a threat to
physical integrity (in the DSM V) with the tenth version of the
International Classication of Disorders manual (ICD 10) still
emphasising that the event must be essentially catastrophic.
In PTSD, the three core symptoms are: trauma re-experience during
sleep and waking hours, avoidance of traumatic memory triggers
(oen accompanied by emotional numbness, depersonalization and
derealisation) and hyperarousal (easy startling) [9]. Over the years, an
important debate has revolved around the application of Western
diagnostic methods to other cultures such as non-Western refugees.
Although diagnostic systems like the ICD 10 are internationally
recognized, they are still predominantly based on a Western
philosophy and so may not holistically consider the cultural inuence
on health perceptions [10].
Notably, the fact that PTSD can develop aer just one traumatic
event highlights the grim reality and psychological consequences that
suerers may experience in the face of continuous multiple traumatic
events [11]. Especially in the case of war and refugees, suerers may
also have to deal with a multitude of additional problems related to
their situation such as homelessness, poverty and physical health
problems which inevitably exacerbate the situation [12]. In the
literature, there is a clear distinction between simple and complex
trauma. Whereas the former-mentioned is oen related to one
traumatic experience such as a car accident, the latter-mentioned may
arise from repetitive traumatic events such as torture. In the case of
complex trauma, individuals may experience deeper psychological and
psychiatric changes than those seen in PTSD [13]. An association
which is evident and highly cited is that between the number of trauma
events and the increased probability of developing PTSD [14].
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ISSN: 2327-5162
Alternative and Integrative Medicine Grech and Grech, Altern Integr Med 2018, 7:2
DOI: 10.4172/2327-5162.1000264
Review Article Open Access
Altern Integr Med, an open access journal
ISSN:2327-5162
Volume 7 • Issue 2 • 1000264

PTSD treatment may include a combination of pharmacotherapy
and psychotherapy though the primary treatment is oen
recommended to be non-drug based [3]. ese are discussed in the
following sections.
Pharmacological treatment
In a comprehensive review of medications for PTSD, the evidence
base is currently strongest for Selective Serotonin Reuptake Inhibitors
(SSRIs) with Sertraline and Paroxetine being the only ones approved
by the Food and Drug Administration (FDA) for use in PTSD [15]. In
particular, in clinical trials, outcome variables for Paroxetine were
statistically signicant but not clinically so [3].
Fluoxetine and Venlafaxine are oen strongly advocated for use
although these may not be so eective in veterans [16]. Although
direct comparisons between pharmacotherapy and psychotherapy are
scarce and oentimes inconclusive, eect sizes resulting from available
research show that overall certain types of psychotherapy such as CBT
are more benecial and should be the routine rst-line treatment [3].
us, pharmacotherapy should only be oered if the individual refuses
to participate in psychotherapy or if trauma-focused psychotherapy
has not proven to be eective [3].
Trauma focused psychotherapy
As noted by Robjant and Fazel, psychological explanations of PTSD
are benecial as they have led to the development of psychological
treatment [9]. Most of the trauma-focused treatment approaches are
primarily based on CBT principles. Some of these techniques are:
Exposure erapy, Trauma-Focused CBT and Cognitive Processing
therapy [3].
Exposure therapy involves a process that exposes and gradually
desensitises the individual to memories, thoughts and feelings related
to the trauma in a safe environment. In most exposure therapy
programmes, such memories are evoked through imagery. It is
postulated that the eectiveness of exposure therapies is attributed to
the ability to enable an individual to discern between past experiences
and current threat [17]. Prolonged Exposure (PE) is one of the
commonly recommended evidence-based exposure treatments for
PTSD and is oen regarded as the gold standard [18]. Developed by
Dr. Edna Foa, this treatment usually entails 9-12 weekly sessions
lasting 90-120 minutes. is therapy involves gradual exposure to
stimuli that are related to the trauma experiences in order to reduce
avoidance and eventually diminish PTSD symptoms. During the
process, relaxation training and the confrontation of distressing
memories are an important component. In a review, the ndings
showed that 86% of subjects who had been following this type of
therapy had a better trajectory than their control group counterparts
[19] although other studies reported that up to 45% of individuals may
still merit a diagnosis following treatment [20]. Moreover, most
research has been carried out on simple and single trauma and so the
eectiveness of PE on complex multiple trauma has not been
thoroughly explored yet [18]. Narrative Exposure erapy, which is
the intervention of interest in this study, is another variant of CBT
which falls underneath the exposure therapy group in PTSD
treatment-this therapy type will be explored in a later section.
Trauma-focused CBT (TF-CBT) is a branch of cognitive therapy
which builds on the premise that in PTSD, symptoms are evoked by
the individual’s interpretation of the trauma rather than by the actual
traumatic event itself [21]. is implies that it is one’s distorted
cognitions that need to be addressed by attempting to correct and
replace these with more realistic and less distressing thoughts. is is
done through a combination of trauma-sensitive techniques and
cognitive behavioral therapy strategies. Typically, TF-CBT lasts
between 12 and 16 sessions [22].
Cognitive processing therapy (CPT) shares similarities to Narrative
Exposure erapy in that it engages the individual in writing a trauma
narrative. During repeated reading of the account, cognitive therapy is
delivered by focusing on control and safety issues [23].
Other therapies which are not predominantly based on CBT include
Eye movement desensitization and reprocessing (EMDR) and
Testimony erapy.
Eye movement desensitization and reprocessing (EMDR) targets the
individual’s reaction to memories of trauma. Essentially, therapy is
delivered by guiding the patient to think and speak about the trauma
whilst focusing on unrelated external stimuli such as sounds or eye
movements [24]. One common practice is for the therapist to move
his/her hand whilst asking the individual to follow this movement with
his/her eyes.
Another therapy that is in use is Testimony erapy which places
the trauma in the cultural socio-political milieu in which it has
occurred. Typically, the process involves 12 sessions during which the
individual narrates his/her life stories with the traumatic experiences
included. e story is presented in a written format and can be read to
signicant others or archived [25].
Discussion
Overview of NET
In 2002, Neuner and colleagues developed a new type of therapy for
PTSD called Narrative Exposure erapy (NET) [15].
NET is an evidence-based treatment that is most commonly used in
the case of multiple traumas resulting from domestic, sexual or
organized violence or abuse, war or natural disasters. e procedure
followed by NET uses Testimony erapy and Cognitive Behavioural
erapy as a base and addresses the same psychological aetiology that
exposure therapies are based on; namely the correction of the
autobiographical memory dysfunction and the habituation to the fear
response [18].
At its simplest, the aim of NET is to facilitate the process of
converting fragmented autobiographic memories related to the
traumatic event into a coherent narrative-the testimony. During this
process, painful emotions are analyzed in a guided manner which
facilitates emotional recovery from the trauma [26].
As guided by the therapist, the individual is engaged in forming a
chronological narrative of his/her life with special focus on the period
of trauma [27]. During this process, the therapist asks the individual to
describe observations, thoughts, emotions and physiological responses
to the traumatic experience in detail whilst ensuring that connection
with the present is not lost. In order to ensure that the individual does
not disconnect with the present, constant reminders are provided in
terms of the fact that the responses being described by the individual
are linked to a traumatic episode that has a time and place in the past.
e description provided by the individual is recorded by the therapist
as a necessity for the compilation of the autobiography [15]. Whereas
in traditional exposure therapy, the therapist asks participants to focus
Citation: Paulann Grech, Reuben Grech (2018) Narrative Exposure Therapy for Post-Traumatic Stress Disorder. Altern Integr Med 7: 1000264.
doi:10.4172/2327-5162.1000264
Page 2 of 6
Altern Integr Med, an open access journal
ISSN:2327-5162
Volume 7 • Issue 2 • 1000264

on the worst traumatic event that they had experienced, NET targets
all traumatic events on the premise that in complex trauma,
individuals may have undergone similarly severe multiple traumas.
us it may not be realistic or indeed therapeutic to focus on just one
of these events [18]. is is also aimed at enhancing a feeling of
personal identity of the person’s life including the traumatic episodes.
Once the biography is extracted, its review by the individual and the
therapist allows for the understanding of the experiences as well as the
behaviour and schemas that emerged as a consequence [27].
Basis of narrative exposure therapy
Whilst human perception is oen regarded as being inuenced by a
direct stimulus, it is also known to be aected by memories of arousing
experiences that have occurred in the past. In the case of any
experience but with specic relevance to traumatic events, the memory
is not just a snapshot of the historic episode but a complex mash of the
actual event and the meaning attributed to it. is remodels cognition,
emotion and behavioral responses to such an extent that the individual
may experience signicant and constant distress even though the
threat is in the past and so no longer exists. In essence, this leads to the
formation of hot and cold memories. e term ‘cold memories’ refers
to those memories which are coherent, factual, salient, organized and
do not cause signicant distress when recalled by the individual [28].
Cold memories are specic to dierent events that occurred in an
individual’s life and are organized in dierent levels with each level
being increasingly specic than the one preceding it [9].
Contrastingly, ‘hot memories’ are painful, distressing disorganized
and disconnected from the plain facts of the original episode. A further
detrimental characteristic of such memories is the tendency for them
to be triggered by a sensory or environmental cue which consequently
activates the individual’s fear response to a stimulus that has actually
occurred in the past [28]. In hot memories, there is an involvement of
the limbic system in the mental representation of the traumatic event
which is what leads to activation of the fear network and the resulting
symptoms such as the ashbacks in PTSD. Neurocircuitry explanations
of PTSD have placed the medial prefrontal cortex (mPFC) and
hippocampus at the forefront of symptom causation. e involvement
of the amygdala is related to hyper-responsiveness which leads to
elevated fear reactions and intrusive traumatic memories.
Contrastingly, the ventromedial prefrontal cortex (vmPFC) may be
hyporesponsive and this fails to inhibit the amygdala. e combination
of these two malfunctions may lead to challenges in emotion
regulation, attention and contextual processing. Additionally, the
malfunctioning of the hippocampus contributes to diculties in
contextual processing, memory processing and neuroendocrine
regulation. More recently, research has suggested that the dorsal
anterior cingulate cortex (dACC) and insular cortex may also be
involved in PTSD [29]. As a consequence of this chain of physiological
abnormalities, the fear network is easily activated in particular due to
an increased number of possible cues and the stronger associations
between these cues [26].
e aim of NET is to reorganize a disordered memory
representation against the backdrop of the individual’s lifeline, thus
enhancing the coding of the declarative autobiographical memory
(cold memories) [9] and giving a temporal and spatial context to
traumatic events. Exposure to the traumatic episodes continues until
the individuals’ arousal is visible diminished [15]. is does not mean
that the meaning attributed to the traumatic event is shunned – it is
altered in a way that allows the individual to perceive the event and
react to its memory in a less distressing manner [30].
Structure of narrative exposure therapy
NET sessions preferably occur at least once per week with no longer
than a fortnight between the sessions. Each session typically lasts
60-120 minutes [31].
e rst step of NET consists of psychoeducation which involves
the provision of information on the process and rationale for NET.
is is followed by the individual’s informed consent for the therapy.
During the rst session, the lifeline is constructed. is is carried out
with the use of a rope which represents the individual’s life from birth
till the present. Part of the rope is le uncoiled so as to represent the
future. e individual is then asked to narrate his/her life in a
chronological manner. Symbols are used to represent life events on the
life line such as owers (for positive events) and stones (for negative
experiences such as the traumatic episodes). is initial exercise is
important both as a means of building a relationship between the
therapist and the patient and as an indicator of the amount of sessions
required. e subsequent sessions consist of the narration of the
person’s life story with particular focus on the traumatic events. Upon
describing the traumatic episodes, the individual is encouraged to
initially provide a general description of the antecedents of the event
from an environmental, physical, cognitive and behavioural
perspective. e actual event is then explored in detail as the therapist
guides the individual to immerse himself/herself in the description for
a period that is deemed to be long enough to allow for habituation to
occur whilst ensuring that the individual remains connected to the
present. Following exposure to the event, the individual is guided to
continue narrating about the stretch of life following the ordeal until
his/her arousal has subsided, at which point the session can be
concluded. Between the sessions, the therapist writes up the narrative
and identies any areas that require further probing. At the beginning
of the subsequent session, the narrative is read to the patient, which
once again serves as an exposure opportunity.
Several sessions and narrations may be required for the individual
to experience a diminished reaction to the event. Following this, the
individual continues with his/her life story narration until the next
traumatic ordeal appears on the lifeline which is once again explored
in detail [9]. Upon addressing all the traumatic events and obtaining a
full testimony from the individual, therapy can conclude with focus on
any hopes and aspirations for the future. e individual is provided
with a copy of the testimonial which oen serves as a useful source of
information for legal proceedings and history purposes [15]. Figure 1
illustrates the framework for NET.
A version of NET for use with children called KIDNET has also
been developed and studied. Whilst this follows the same procedure as
the adult version, it allows for child-friendly amendments [15].
Apart from its eectiveness, the main strength of this type of
therapy is its relative simplicity such that it can be taught to lay people
without a psychosocial background. is makes the therapy accessible
and handy for use in emergency situations. Another advantage related
to NET is the fact that many cultures already hold storytelling as a
traditional practice in everyday life and so they may easily embrace
and identify to the narrative process of NET [32].
Citation: Paulann Grech, Reuben Grech (2018) Narrative Exposure Therapy for Post-Traumatic Stress Disorder. Altern Integr Med 7: 1000264.
doi:10.4172/2327-5162.1000264
Page 3 of 6
Altern Integr Med, an open access journal
ISSN:2327-5162
Volume 7 • Issue 2 • 1000264

Figure 1: Narrative Exposure erapy framework [26].
Current evidence base and recommendations
e search for literature was initiated by identifying a number of
keyterms that could locate suitable studies as guided by the Cochrane
Guide for Systematic Reviews [33] and by carrying out focussed and
exploded keyword searches on the MeSH On Demand interface. e
databases selected were Cochrane Central Register of Controlled
Trials, EMBASE, MEDLINE and PsycINFO. Filters and limiters were
used accordingly in order to limit the results to those which are
specically and directly suitable to the research question set. e
bibliographies and reference list of relevant articles and reviews were
reviewed in order to attempt to identify further potentially suitable
articles.
Several trials and reviews have attempted to explore the
eectiveness of NET and overall the results are encouraging.
In most of the clinical trials involving NET, the primary outcome
measured was a change in PTSD symptoms from baseline to an
assessment carried out aer 3-6 months. Generally, outcomes were
congruent in presenting a higher dierence in the PTSD symptoms’
mean score aer 3-6 months in the NET group than in the comparator
group. However the level of signicance was reached in some of the
trials [34-39] but not so in others [32,40-42].
One of the clinical trials that was conducted compared NET to
Psychoeducation [35]. is resulted in a signicant reduction in
traumatic symptoms in the NET group aer a 6 month follow up. In
fact a signicant Time of examination x Treatment group interaction
(F(1, 16)=20.80, p<.001, n2=0.60) was obtained and in the NET group,
the pre-post mean change in PTSD symptom score was 6.4 points as
compared to 1.5 points in the other group. Additionally, at the 6-
month assessment point, 56% of the NET participants no longer met
the criteria for a clinical PTSD diagnosis as compared to only 11% of
the cases in the NTFT arm. Another randomized controlled trial
presented similar outcomes [34]. Aer four months of exposure to
NET or pharmacotherapy, signicant improvement in PTSD symptom
severity was only noticeable in the NET group (p<.001). Interestingly,
individuals in the comparator group had a worsening of symptoms
(average score deterioration of 15.9 points). At this point, almost half
of the NET participants (45.5%) no longer satised diagnostic criteria
whilst all the patients in the other group were still diagnosed with
PTSD.
Similarly, in another trial comparing NET to Interpersonal erapy
(IPT) it was found that at aer six months of either NET or IPT, the
NET group’s PTSD score was lower than the other group (a change in
mean score of 28 points in NET as compared to no change in the IPT
group) [39]. Aer 6 months, only 25% of NET individuals with a pre-
test PTSD diagnosis still satised the diagnostic criteria. Contrastingly,
in the comparator group, 71.4% of individuals had a persistent
diagnosis of PTSD. ere was a signicant dierence between the
groups (p<0.05). On reecting on the better outcome of NET in this
study as compared to other trials, it is possible that this is due to the
fact that the participants had multiple losses in their lives and so a grief
session was oered as part of the NET package, thus aecting results.
In another trial, the 6-month follow-up point revealed a 24-point score
dierence in the pre-post symptom assessment in the NET group aer
6 months of treatment. Contrastingly a smaller change of 16.9 points
was achieved in the other group which consisted of an Academic Catch
Up programme [36].
Although in other clinical trials [37,38,42] outcomes were in favour
of NET, the results were less positive or signicantly dierent when
compared to the other trials described. In the rst of these studies, 64%
of the NET participants had an improved PTSD score aer 6 months
(with 45.5% of them no longer meeting PTSD diagnostic criteria)
whilst in the comparator group (Treatment as Usual), only 4.3% of the
subjects had a symptomatic improvement score [42]. Although this
looks like a very promising outcome, the researchers acknowledged
that during the study, refuge status was awarded to more of the NET
participants than those in the other group and so this could have let to
alleviation of symptoms in the NET group. In the subsequent study,
there was a signicant symptomatic dierence between the NET and
comparator group participants aer 4 months of treatment [38].
Participants in the non-NET arm received medication and non-trauma
based psychotherapy. Aer 1 year, there was improvement in both
groups with signicant between-group dierences (X2(2, N=8)=9.48,
p<.01). More improvement was evident in the NET participants
(F(1,106)=14.00, p<.01). However half of the participants of the NET
group were still suering from severe symptoms even aer a 1-year
time lapse. e authors noted that despite this outcome, which is
rather poor as compared to other trials, the administration of NET
seemed to have a strong eect on participants’ decision to leave the
refugee camp to start a new life aer one year. Similarly, in another
trial, the participants seem to fare worse than in other trials [37].
Although 63% of the NET participants (as compared to 16% in the
other group) improved signicantly over a 6-month period, only one
patient remitted completely. In this regard, there was no signicant
dierence from the comparator group (psychoeducation). As a
possible explanation, the authors noted that the participants in the
study had a higher initial pre-test PTSD symptoms score as compared
to those in other trials. Extraneous variables such as family separation
and the persistent threat of deportation could have also been in eect.
In three other trials, there was an improvement in PTSD symptoms
in the NET group but it was not enough to reach signicance as
compared to improvement in comparator group [32,40,41]. However
there were other important changes in relation to NET. For instance, in
one of the studies, good results were obtained with less training and
sessions as compared to the other arm which consisted of participants
who received the best practice standard German treatment for
Borderline Personality Disorder [40]. In another trial [32] signicant
Citation: Paulann Grech, Reuben Grech (2018) Narrative Exposure Therapy for Post-Traumatic Stress Disorder. Altern Integr Med 7: 1000264.
doi:10.4172/2327-5162.1000264
Page 4 of 6
Altern Integr Med, an open access journal
ISSN:2327-5162
Volume 7 • Issue 2 • 1000264

dierences were evident in the NET groups’ well-being (paired
t(34)=-3.66, p=.001, d=0.87), post-traumatic growth (paired
t(34)=2.35, p=.025, d=0.41) and a meaningful (but not signicant)
decrease of symptom interference in daily functioning (paired
t(30)=1.82, p=.079).
In a qualitative review, 16 trials were included which compared NET
to Supportive Counseling, Psychoeducation, Interpersonal erapy
Meditation-Relaxation and Waiting List [9]. e review conclusively
provided evidence that NET is helpful in alleviating acute and chronic
PTSD. Similarly, in a meta-analytic review which targeted studies that
involved refugee populations only [10], the combined outcomes of
seven quantitative studies demonstrated the eectiveness of NET with
an adequate eect size and statistical power. is led to the authors to
conclude that lay counselors should be empowered by being trained to
deliver NET to fellow refugees.
Conclusion
Trials and reviews such as the ones described have been successful
in building a sound evidence-base for NET. In view of this, further
research is required to continue to explore the potential benets of this
therapy. Primarily, it would be fruitful to engage in trials with larger
sample sizes and with enough inter-trial uniformity to allow for further
meta-analytic approaches of the combined outcomes. Furthermore, the
majority of the studies that have been conducted arise from the
quantitative paradigm. Whilst this has been benecial in exploring the
‘width’ of the subject by allowing for the estimation of the statistical
signicance of results, it is also desirable to address the depth of the
subject by engaging in qualitative or mixed research such as a mixed
method study carried out recently in the Netherlands [43]. is will
introduce an important tangent to the information that is already
available by extracting meaning and perception from participants and
therapists who have engaged in this therapy.
ere is limited data arising from PTSD suerers in lower-income
countries yet this is ironic since in these countries, there is a high rate
of PTSD in refugees. In this population, the type of PTSD experienced
may be more complex and involving multiple events-characteristics
which may aect the outcome of therapy and thus worth exploring in
more detail through further research initiatives [32].
e fact that NET was specically developed for use with
populations who may have experienced multiple trauma such as
refugees reects in the fact that most of available literature is based on
research conducted in a very specic setting, commonly refugee
settlements–this gives rise to a generalizability issue which makes it
hard to determine the eectiveness of NET outside of these
populations. It would be interesting to expand the scope of NET by
exploring its application to other trauma-related situations that are not
necessarily a byproduct of organized violence or natural disasters.
It may also be fruitful to continue exploring the eectiveness of
NET as an adjunct treatment to other psychotherapies, physical
therapies or pharmacotherapy. An example of such research was
presented in a recent study during which physiotherapy was combined
with NET in the treatment of chronic pain in torture victims [44].
Furthermore, it is of utmost importance to place further focus on
the eect of culture and context when diagnosing and managing
disorders such as PTSD. is is due to the fact that the majority of the
available studies on the subject have not compared NET to other ways
of dealing with suering in that particular culture which may (or may
not) be as eective. Furthermore studies on how NET testimonials
have been used in human rights proceedings may enhance the
ecological validity of NET [45].
Finally, on reecting on the potential benets of NET, it may be
worth dedicating more training initiatives in countries where trauma-
specic care is limited and which experience a high inux of refugees.
Since Narrative Exposure erapy training is concise, it may be
relatively simple to incorporate it in health care professionals’
undergraduate/postgraduate curriculum or continuous professional
development training. Ideally this would be part of a Trauma-
Informed approach which is built on the premise that many
individuals who seek help do not realize that their past traumatic
experiences may have a strong link with current psychological
diculties. Similarly care providers may ignore the signicance of
these traumatic experiences and/or may not address them
appropriately [46]. In this way, it has to be noted that the NET process,
especially the setting of the lifeline may help to extract a detailed
history from the individual which may subsequently shed light on
important traumatic events.
Conict of interest
e authors declare no conicting interests.
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Citation: Paulann Grech, Reuben Grech (2018) Narrative Exposure Therapy for Post-Traumatic Stress Disorder. Altern Integr Med 7: 1000264.
doi:10.4172/2327-5162.1000264
Page 6 of 6
Altern Integr Med, an open access journal
ISSN:2327-5162
Volume 7 • Issue 2 • 1000264