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Narrative Exposure Therapy (NET)

Topic Areas
Scientific Rating
Child Welfare Relevance
Trauma Treatment (Adult)
1  — Well-Supported by Research Evidence
Low

About This Program

Target Population: Adult survivors of organized violence, war, conflict, torture, man-made and natural disasters, civil trauma as well as childhood sexual/physical abuse, mistreatment and neglect

Program Overview

Narrative Exposure Therapy (NET) is a culturally universal intervention. Given its focus on the autobiographical elaboration of traumatic experiences, NET is particularly suited for populations affected by multiple and continuous traumatic experiences, such as organized violence, torture, war, rape, and childhood abuse. NET has been developed as a standardized short-term approach. It is designed so that three to six sessions should be sufficient to provide considerable relief and reinstate individual functioning, even for patients who suffer from severe and chronic traumatization in areas of on-going adversity and recent disasters. Beyond its focus on healing the wounds of trauma, NET aims to account for the human rights abuses suffered by survivors. Beyond the core components of classic NET described in this entry and on which the CEBC has rated the program, there are newly developed treatment modules for the rehabilitation of traumatized children (KIDNET), as well as Forensic Offenders (FORNET) as well as a module on the theory and practical management of dissociation.

Program Goals

The goals of Narrative Exposure Therapy (NET) are:

  • Significantly reduced clinical symptomatology of PTSD
  • Significantly reduced clinical symptomatology of co-morbid trauma-spectrum pathology, especially depression, anxiety, suicidality, substance abuse depending on the patient population also reduction of borderline symptoms, self-harm, aggressive acting out
  • Significantly reduced clinical symptomatology of trauma associated features, especially feelings such as guilt and shame
  • Significantly improved personal functioning at the social, occupational, scholastic, emotional level
  • Significantly improved family and community functioning (depending on patient population) at the level of readiness for forgiveness and reconciliation, community cohesion, readiness for (re-)integration as a civilian, reduction of re-recruitment, among other
  • Significantly improved health indicators (T-cell recovery, DNA recovery)
  • Independently functioning therapist and psycho-social counselor groups/outpatient clinics in severely underserved regions
  • Documentation and acknowledgement of human rights abuse at the individual, family, community, state levelglobally, such as regions of complex emergency and conflict
  • Public mental health education on trauma spectrum disorders and their treatment
  • Fostering truth, reconciliation and compassion for survivors as well as perpetrators, at the community and individual level

Logic Model

The program representative did not provide information about a Logic Model for Narrative Exposure Therapy (NET).

Essential Components

The essential components of Narrative Exposure Therapy (NET) include:

  • Active chronological reconstruction of the autobiographical/episodic memory
  • Imaginal exposure to the traumatic events ("hot spots") and full activation of the fear memory in order to modify the emotional network through detailed narration and imagination of the traumatic events
  • Meaningful linkage and integration of physiological, sensory, cognitive, and emotional responses to one's time, space, and life context (i.e., comprehension of the original context of acquisition and the reemergence of the conditioned responses in later life)
  • Cognitive re-evaluation of behavior and patterns (e.g., cognitive distortions, automatic thoughts, beliefs, responses), as well as reinterpretation of the meaning/content through reprocessing of negative, fearful, and traumatic events until completion and closure
  • Revisiting of positive life-experiences to activate resources and to adjust basic assumptions
  • Regaining of the survivor's dignity through satisfaction of the need for acknowledgment through the explicit human rights orientation of testifying

Program Delivery

Adult Services

Narrative Exposure Therapy (NET) directly provides services to adults (regardless of whether they are parents or caregivers) and addresses the following:

  • Psychopathology of the trauma spectrum (PTSD, depression, substance abuse, aggressive acting out, anxiety, among other); dysfunctionality in emotional, social, occupational, scholastic functioning; family violence, abuse, neglect; problems of the asylum/refugee spectrum (unaccompanied minors, etc.); problems of offending youth/young adult/children
Services Involve Family/Support Structures:

This program involves the family or other support systems in the individual's treatment: Depending on the global region, support for patients is sought via health care facilities, spiritual leaders, teachers, counselors, social workers, human rights advocates (i.e. amnesty international) among other. Usually many members of a given project community are affected by the trauma suffered by the individual patient, so a number of support systems can be involved. Usually the trained lay counselor originates from the survivor community.

Recommended Intensity:

90- to 120-minute sessions at least once every week, ideally twice (with at least 1-2 day break in between to allow for mental consolidation and a couple of nights sleep)

Recommended Duration:

4-12 sessions over approximately 6-8 weeks

Delivery Settings

This program is typically conducted in a(n):

  • Hospital
  • Outpatient Clinic
  • Community-based Agency / Organization / Provider
  • School Setting (Including: Day Care, Day Treatment Programs, etc.)

Homework

This program does not include a homework component.

Languages

Narrative Exposure Therapy (NET) has materials available in languages other than English:

Dutch, French, German, Italian, Japanese, Korean

For information on which materials are available in these languages, please check on the program's website or contact the program representative (contact information is listed at the bottom of this page).

Resources Needed to Run Program

The typical resources for implementing the program are:

  • Trained counselors (can be lay people and/or doctors, nurses, psychotherapists, psychiatrists, counselors, teachers, social workers, pastors, community agents, among other). Trainees must be willing to undergo training related self-awareness during workshop and participate actively. Ideal participants are individuals who can make sufficient time in their work TOR (check/adapt individual work plan) to actually apply NET regularly
  • Trained translators (if patient does not speak counselors' language)
  • Safe and private room

Manuals and Training

Prerequisite/Minimum Provider Qualifications

Counselors must have undergone training on NET and be able to read, write and be compassionate. In its core, NET training is assumed to be an approach, which is easily able to be disseminated to lay counselors in areas of need.

Manual Information

There is a manual that describes how to deliver this program.

Training Information

There is training available for this program.

Training Contact:
Training Type/Location:

Depending on trainees' circumstances, training can be arranged at trainees' home base. Regular NET workshops take place in Germany at the Center of Excellence in Konstanz (also in English language).

Number of days/hours:

2 – 4 full days for professional counselors/psychotherapists (full attendance is required, since workshop units have an in-built logic). Approx. 3 weeks for lay counselors in areas of complex emergency or need (full attendance is required, since workshop units have an in-built logic).

Additional Resources:

There currently are additional qualified resources for training:

There are NET trainers in many countries around the globe already. For specific information, please contact Heike Riedke at heike.riedke@vivo.org. The Konstanz center can provide supervision, also via skype or other media to trained individuals in various languages.

Implementation Information

Pre-Implementation Materials

There are no pre-implementation materials to measure organizational or provider readiness for Narrative Exposure Therapy (NET).

Formal Support for Implementation

There is formal support available for implementation of Narrative Exposure Therapy (NET) as listed below:

Trainers, training manual, trauma screening questionnaires, supervision live & via Skype (also during program build-up, as well as for treatment support and post-testing). Descriptions on how large-scale programs were built up in the field are also available.

Fidelity Measures

There are no fidelity measures for Narrative Exposure Therapy (NET).

Implementation Guides or Manuals

There are implementation guides or manuals for Narrative Exposure Therapy (NET) as listed below:

There are brief outlines of the training as well as an assessment manual available for field trained lay counselors

Research on How to Implement the Program

Research has been conducted on how to implement Narrative Exposure Therapy (NET) as listed below:

  • 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), 503–512. https://doi.org/10.1001/jama.2011.1060
  • Schaal, S., Elbert, T., & Neuner, F. (2009). Narrative exposure therapy versus interpersonal psychotherapy: A pilot randomized controlled trial with Rwandan genocide orphans. Psychotherapy and Psychosomatics, 78, 298–306. https://doi.org/10.1159/000229768

Relevant Published, Peer-Reviewed Research

Child Welfare Outcome: Child/Family Well-Being

Neuner, F., Schauer, M., Klaschik, C., Karunakara, U., & Elbert, T. (2004) A comparison of Narrative Exposure Therapy, supportive counseling, and psychoeducation for treating posttraumatic stress disorder in an African refugee settlement. Journal of Consulting and Clinical Psychology, 72(4), 579–587. https://doi.org/10.1037/0022-006X.72.4.579

Type of Study: Randomized controlled trial
Number of Participants: 43

Population:

  • Age — Approximately 33 years
  • Race/Ethnicity — 100% Sudanese
  • Gender — 27 Female and 16 Male
  • Status — Participants were adults living in a refugee camp.

Location/Institution: The Imvepi settlement in Northern Uganda

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to evaluate the efficacy of Narrative Exposure Therapy (NET) in Sudanese refugees living in a refugee settlement who were diagnosed as suffering from posttraumatic stress disorder (PTSD). Participants were randomly assigned to either NET, supportive counseling (SC), or psychoeducation (PE). Measures utilized include the Demography of Forced Migration Questionnaire (DFMQ), the Posttraumatic Stress Diagnostic Scale (PDS), the Self-Reporting Questionnaire 20 (SRQ-20), the 12-item version of the Medical Outcome Study Self-Report Form, and the PTSD portion of the Composite International Diagnostic Interview (CIDI). Results indicate that at posttreatment only 29% of the NET participants, but 79% of the SC group and 80% of the PE group still fulfilled PTSD criteria. Limitations include small sample size and possible dosage effect as the exact duration of each individual treatment session was not monitored.

Length of controlled postintervention follow-up: 1 year.

Bichescu, D., Neuner, F., Schauer, M., & Elbert, T. (2007). Narrative Exposure Therapy for political imprisonment-related chronic posttraumatic stress disorder and depression. Behaviour Research and Therapy, 45(9), 2212–2220. https://doi.org/10.1016/j.brat.2006.12.006

Type of Study: Randomized controlled trial
Number of Participants: 18

Population:

  • Age — Mean=69 years
  • Race/Ethnicity — Not specified
  • Gender — 17 Male and 1 Female
  • Status — Participants were political detainees who showed no sign of mental disabilities.

Location/Institution: Association of Former Political Detainees in Iasi and Brasov and at the University ˜A.I. Cuza in Iasi in Romania

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to evaluate the usefulness of Narrative Exposure Therapy (NET) in comparison with psychoeducation (PED). Participants were randomly assigned to NET or PED. Measures utilized were the Mini Mental State Inventory (MMSI), Composite International Diagnostic Interview (CIDI), and the Beck Depression Scale (BDI). Results indicate that improvements in posttraumatic symptom categories after NET were noticed with regard to avoidance and arousal. Depression scores were also significantly reduced in the NET group as compared to those in the PED group. Six months after the end of treatment, 44% of the NET group still had PTSD, compared to 89% with PTSD in the PED group. Limitations include small sample size and the limited blindness of the interviewers.

Length of controlled postintervention follow-up: 6 months.

Neuner, F., Onyut, P. L., Ertl, V., Odenwald, M., Schauer, E., & Elbert, T. (2008). Treatment of posttraumatic stress disorder by trained lay counselors in an African refugee settlement: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 76(4), 686–694. https://doi.org/10.1037/0022-006X.76.4.686

Type of Study: Randomized controlled trial
Number of Participants: 277

Population:

  • Age — Mean=43.1 years
  • Race/Ethnicity — 152 Rwandan and 125 Somali
  • Gender — 60% Male
  • Status — Participants were adults living in a refugee camp.

Location/Institution: The Nakivale refugee settlement in Uganda

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to examine whether trained lay counselors can carry out effective treatment of posttraumatic stress disorder (PTSD) in a refugee settlement. Participants were randomly assigned to Narrative Exposure Therapy (NET), trauma counseling (TC), or a no-treatment monitoring group (MG). Measures utilized include the Posttraumatic Stress Diagnostic Scale (PDS) and the Composite International Diagnostic Interview (CIDI). Results indicate that both NET and TC were statistically and clinically superior to MG on posttraumatic stress disorder (PTSD) symptoms and physical health, but did not differ from each other. Results also indicate that PTSD diagnosis could not be established anymore in 70% of NET and 65% of TC participants, whereas only 37% in MG did not meet PTSD criteria anymore. Limitations include high attrition rate at follow-up and concerns regarding randomization, which resulted in a significantly different group composition with regard to nationality.

Length of controlled postintervention follow-up: 6 months.

Neuner, F., Kurreck, S., Ruf, M., Odenwald, M., Elbert, T., & Schauer, M. (2010). Can asylum-seekers with posttraumatic stress disorder be successfully treated? A randomized controlled pilot study. Cognitive Behaviour Therapy, 39(2), 81–91. https://doi.org/10.1080/16506070903121042

Type of Study: Randomized controlled trial
Number of Participants: 32

Population:

  • Age — Approximately 31 years
  • Race/Ethnicity — 25 Turkish, 4 Balkan, and 3 African
  • Gender — 22 Male and 10 Female
  • Status — Participants were asylum seekers who have posttraumatic stress disorder (PTSD).

Location/Institution: Psychological Research and Outpatient Clinic for Refugees at the University of Konstanz

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to examine the efficacy of trauma-focused treatment in asylum-seekers with PTSD resulting from state-sponsored violence and other traumatic events. Participants were randomly allocated into either Narrative Exposure Therapy (NET) or treatment as usual (TAU). Measures utilized include the Posttraumatic Stress Diagnostic Scale (PDS), the Clinician Administered PTSD Scale (CAPS), the Vivo-Checklist of Organized Violence (VCOV), the Composite International Diagnostic Interview (CIDI-C), and the Hopkins Symptom Checklist–25 (HSCL). Results indicate that a significant reduction of posttraumatic stress symptoms was found in the NET participants, but not in the TAU group. There was also a significantly better trajectory for NET patients than TAU patients in the follow-up months after treatment in terms of PTSD and pain symptoms, but no difference related to depression symptoms. Limitations include small sample size and possible dosage effect of unspecific treatment factors.

Length of controlled postintervention follow-up: 6 months.

Adenauer, H., Catani, C., Gola, H., Keil, J., Ruf, M., Schauer, M., & Neuner, F. (2011). Narrative Exposure Therapy for PTSD increases top-down processing of aversive stimuli - evidence from a randomized controlled treatment trial, BMC Neuroscience, 12(1), Article 127. https://doi.org/10.1186/1471-2202-12-127

Type of Study: Randomized controlled trial
Number of Participants: 34

Population:

  • Age — 11–56 years
  • Race/Ethnicity — Not specified
  • Gender — Not specified
  • Status — Participants were refugees with posttraumatic stress disorder (PTSD).

Location/Institution: Outpatient Clinic for Refugees, University of Konstanz, Germany

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to examine whether Narrative Exposure Therapy (NET) causes changes in affective stimulus processing in patients with chronic PTSD. Participants were randomly allocated to a NET group or to a waitlist control (WLC) group. Measures utilized include the Hamilton Depression Scale (HAM-D). Results indicate PTSD as well as depressive symptom severity scores declined in the NET group, whereas symptoms persisted in the WLC group. Only in the NET group, parietal and occipital activity towards threatening pictures increased significantly after therapy. Limitations include small sample size, loss of data, and length of follow-up.

Length of controlled postintervention follow-up: 4 months.

Zang, Y., Hunt, N., & Cox, T. (2013). A randomised controlled pilot study: The effectiveness of Narrative Exposure Therapy with adult survivors of the Sichuan earthquake. BMC Psychiatry, 13, Article 41. https://doi.org/10.1186/1471-244X-13-41

Type of Study: Randomized controlled trial
Number of Participants: 22

Population:

  • Age — Approximately 55 years
  • Race/Ethnicity — 100% Chinese
  • Gender — 17 Female and 5 Male
  • Status — Participants were Chinese earthquake survivors.

Location/Institution: Beichuan County, China

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to evaluate the efficacy of Narrative Exposure Therapy (NET) as a short-term treatment for posttraumatic stress disorder (PTSD) with Chinese earthquake survivors. Participants were randomly allocated to NET or a waiting list (WL) condition. Measures utilized were the Impact of Event Scale-Revised (IES-R), the General Health Questionnaire-28 (GHQ-28), the Hospital Anxiety and Depression Scale (HADS), the Short Form of the Changes in Outlook Questionnaire (CiQQ-S), the Multidimensional Scale of Perceived Social Support (MSPSS), and the Simplified Coping Style Questionnaire (SCSQ). Results indicate that compared with WL, NET showed significant reductions in PTSD symptoms, anxiety and depression, general mental stress, and increased posttraumatic growth. The WL group later showed similar improvements after treatment. These changes remained stable for follow-up. Limitations include small sample size and the lack of a longer term follow up.

Length of controlled postintervention follow-up: 2 months.

Stenmark, H., Catani, C., Neuner, F., Elbert, T., & Holen, A. (2013). Treating PTSD in refugees and asylum seekers within the general health care system. A randomized controlled multicenter study. Behaviour Research and Therapy, 51(10), 641–647. https://doi.org/10.1016/j.brat.2013.07.002

Type of Study: Randomized controlled trial
Number of Participants: 81

Population:

  • Age — Mean=35 years
  • Race/Ethnicity — 56 Male and 25 Female
  • Gender — Not specified
  • Status — Participants were refugees and asylum seekers with posttraumatic stress disorder (PTSD).

Location/Institution: Norway

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to compare Narrative Exposure Therapy (NET) to treatment as usual (TAU) in 11 general psychiatric health care units in Norway. The focus was on changes in symptom severity and in the diagnostic status for PTSD and depression. Participants were randomized to either NET or TAU. Measures utilized include the Clinician Administered Post Traumatic Stress Disorder Scale (CAPS), Hamilton Rating Scale for Depression (HRS-D), and the MINI Neuropsychiatric Interview. Results indicate that both NET and TAU gave clinically relevant symptom reduction both in PTSD and in depression. NET gave significantly more symptom reduction compared to TAU as well as significantly more reduction in participants with PTSD diagnoses. No difference in treatment efficacy was found between refugees and asylum seekers. Limitations include small sample size, assessment tools were not validated to the language and culture of each asylum seeker or refugee, and length of follow-up.

Length of controlled postintervention follow-up: 1 month and 6 months.

Pabst, A., Schauer, M., Bernhardt, K., Ruf-Leuschner, M., Goder, R., Elbert, T., Rosentraeger, R., Robjant, K., Aldenhoff, J., & Seeck-Hirschner, M. (2014). Evaluation of Narrative Exposure Therapy (NET) for borderline personality disorder with comorbid posttraumatic stress disorder. Clinical Neuropsychiatry, 11(3), 108–117. https://psycnet.apa.org/record/2014-55266-002

Type of Study: Randomized controlled trial
Number of Participants: 22

Population:

  • Age — 29–30 years
  • Race/Ethnicity — Not specified
  • Gender — 100% Female
  • Status — Participants were women in an outpatient psychiatric center.

Location/Institution: Center for Integrative Psychiatry in Kiel, Germany

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to evaluate the efficacy of either Narrative Exposure Therapy (NET) or a standard treatment by experts (TBE) for borderline personality disorder. Participants were assigned to NET or TBE. Measures utilized were the Mini-International Neuropsychiatric Interview, and Hamilton Rating Depression Scale, Structured Clinical Interview approaches (SCID II), Borderline Symptom Checklist (BSL-23), Hopkins Symptom Checklist 25 (HSCL-25), and the German short version of the Dissociative Experience Scale (DES). Results indicate that both treatment forms reduced all of the symptoms (PTSD, borderline, depression and dissociation) substantially. The decrease continued throughout the 12 month follow-up period producing large effects. Greatest effect sizes were obtained for the reduction of PTSD symptoms by NET and depression. Limitations include small sample size, low generalizability due to gender, and reliability on self-reported measures.

Length of controlled postintervention follow-up: 1 year.

Jacob, N., Neuner, F., Maedl, A., Schaal, S., & Elbert, T. (2014). Dissemination of psychotherapy for trauma-spectrum disorders in resource-poor countries: A randomized controlled trial in Rwanda. Psychotherapy and Psychosomatics, 83(6), 354–363. https://doi.org/10.1159/000365114

Type of Study: Randomized controlled trial
Number of Participants: 76

Population:

  • Age — 29–30 years
  • Race/Ethnicity — Not specified
  • Gender — 100% Female
  • Status — Participants were widows or orphan survivors of the 1994 Rwandan genocide with posttraumatic stress disorder (PTSD).

Location/Institution: Huye, Mbazi, Mukura, Ngoma, and Tumba of the Huye District of Rwanda

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to test a train-the-trainer (TTT) dissemination model for the treatment of posttraumatic stress disorder (PTSD). Participants were randomly assigned to Narrative Exposure Therapy (NET) treatment (NET-1) or to a 6-month waiting list (WL) condition to be followed by treatment (WL/NET-2). Measures utilized were the Mini-International Neuropsychiatric Interview, Hopkins Symptom Checklist 25 (HSCL-25), Clinician-Administered PTSD Scale (CAPS), and the PTSD Symptom Scale Interview (PSS-I). Results indicate that at the 3-month follow-up, the NET-1 participants suffered significantly and substantially less from PTSD symptoms than the participants in the WL/NET-2 group. The treatment gains of NET-1 were maintained and increased at follow-up. After treatment by the second dissemination generation of therapists, the WL/NET-2 participants improved to an extent similar to that of the NET-1 group at follow-ups. Limitations include small sample size, and testing may affect the development of symptom reports.

Length of controlled postintervention follow-up: 3 and 12 months.

Additional References

Elbert, T., Schauer, M., & Neuner, F. (2015). Narrative Exposure Therapy (NET): Reorganizing memories of traumatic stress, fear, and violence. In U. Schnyder & M. Cloitre (Eds.), Evidence-based treatments for trauma-related psychological disorders: A practical guide for clinicians (pp. 229-253). Springer.

Schauer, M. (2015). Narrative Exposure Therapy. In: J. Wright (Ed.), International encyclopedia of social & behavioral sciences (2nd ed., pp. 198–203). Elvelsior.

Schauer M., Neuner, F., & Elbert, T. (2011). Narrative Exposure Therapy (NET). A short-term intervention for traumatic stress disorders (2nd ed.). Hogrefe & Huber Publishers.

Contact Information

Maggie Schauer, PhD, MA
Agency/Affiliation: University of Konstanz, Germany & Vivo International
Website: www.vivo.org/en/narrative-expositionstherapie
Email:

Date Research Evidence Last Reviewed by CEBC: September 2022

Date Program Content Last Reviewed by Program Staff: October 2023

Date Program Originally Loaded onto CEBC: October 2013