Advertisement

Narrative Exposure Therapy (NET) as a Treatment for Traumatized Refugees and Post-conflict Populations

  • Frank NeunerEmail author
  • Thomas Elbert
  • Maggie Schauer
Chapter

Abstract

Humans are experiencing wars that target primarily civilians and that are characterized by mass recruitment into armed forces and atrocities. An increasing number of victims is forced to flee from wars and persecution. Following the traumatic events experienced in the context of war and flight, a large proportion of post-conflict populations and refugees is traumatized. Refugees face additional stressors as host countries are not well prepared to meet the mental health needs of incoming refugees. Narrative Exposure Therapy (NET) is a short-term, robust, low-threshold, evidence-based and disseminable treatment module that aims to restore psychosocial functioning while counteracting human rights violations. This treatment has proven to reduce posttraumatic stress disorder even for war victims living in low resource settings and conditions of ongoing threat.

Keywords

PTSD Refugee Treatment Narration Trauma-focus 

References

  1. 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), 127.  https://doi.org/10.1186/1471-2202-12-127 CrossRefPubMedPubMedCentralGoogle Scholar
  2. Arnsten, A. F. T. (2009). Stress signalling pathways that impair prefrontal cortex structure and function. Nature Reviews Neuroscience, 10(6), 410–422.  https://doi.org/10.1038/nrn2648 CrossRefPubMedPubMedCentralGoogle Scholar
  3. Bisson, J. I., Ehlers, A., Matthews, R., Pilling, S., Richards, D., & Turner, S. (2007). Psychological treatments for chronic post-traumatic stress disorder. Systematic review and meta-analysis. The British Journal of Psychiatry, 190(2), 97–104.  https://doi.org/10.1192/bjp.bp.106.021402 CrossRefPubMedGoogle Scholar
  4. Bowlby, J. (1982). Attachment (Vol. 2). New York, NY: Basic Books.Google Scholar
  5. Bracha, H. S. (2004). Freeze, flight, fight, fright, faint: Adaptationist perspectives on the acute stress response spectrum. CNS Spectrums, 9(9), 679–685.CrossRefPubMedGoogle Scholar
  6. Brewin, C. R. (2013). Episodic memory, perceptual memory, and their interaction: Foundations for a theory of posttraumatic stress disorder. Psychological Bulletin, 140(1), 69–97.  https://doi.org/10.1037/a0033722 CrossRefPubMedGoogle Scholar
  7. Brewin, C. R., Dalgleish, T., & Joseph, S. (1996). A dual representation theory of posttraumatic stress disorder. Psychological Review, 103(4), 670–686.CrossRefPubMedPubMedCentralGoogle Scholar
  8. Cannon, W. B. (1915). Bodily changes in pain, hunger, fear, and rage: An account of recent researches into the function of emotional excitement. New York, NY/London, UK: D. Appleton and Company.CrossRefGoogle Scholar
  9. Catani, C. (2010). War at home – a review of the relationship between war trauma and family violence. Verhaltenstherapie, 20(1), 19–27.CrossRefGoogle Scholar
  10. 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(1), 22.  https://doi.org/10.1186/1471-244X-9-22 CrossRefPubMedPubMedCentralGoogle Scholar
  11. Chaouloff, F. (2013). Social stress models in depression research: What do they tell us? Cell and Tissue Research, 354(1), 179–190.  https://doi.org/10.1007/s00441-013-1606-x CrossRefPubMedPubMedCentralGoogle Scholar
  12. Cohen, H., Liberzon, I., & Richter-Levin, G. (2009). Exposure to extreme stress impairs contextual odour discrimination in an animal model of PTSD. The International Journal of Neuropsychopharmacology, 12(3), 291–303.  https://doi.org/10.1017/S146114570800919X CrossRefPubMedGoogle Scholar
  13. Conway, M. A., & Pleydell-Pearce, C. W. (2000). The construction of autobiographical memories in the self-memory system. Psychological Review, 107(2), 261–288.CrossRefPubMedGoogle Scholar
  14. Craske, M. G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury, N., & Baker, A. (2008). Optimizing inhibitory learning during exposure therapy. Behaviour Research and Therapy, 46(1), 5–27.  https://doi.org/10.1016/j.brat.2007.10.003 CrossRefPubMedGoogle Scholar
  15. Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy, 58, 10–23.  https://doi.org/10.1016/j.brat.2014.04.006 CrossRefPubMedPubMedCentralGoogle Scholar
  16. Crumlish, N., & O'Rourke, K. (2010). A systematic review of treatments for post-traumatic stress disorder among refugees and asylum-seekers. The Journal of Nervous and Mental Disease, 198(4), 237–251.  https://doi.org/10.1097/NMD.0b013e3181d61258 CrossRefPubMedGoogle Scholar
  17. Eberle-Sejari, R., Nocon, A., & Rosner, R. (2015). Zur Wirksamkeit von psychotherapeutischen Interventionen bei jungen Flüchtlingen und Binnenvertriebenen mit posttraumatischen Symptomen. Kindheit und Entwicklung, 24, 156–169.CrossRefGoogle Scholar
  18. Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38(4), 319–345.CrossRefPubMedPubMedCentralGoogle Scholar
  19. Ehlers, A., Bisson, J., Clark, D. M., Creamer, M., Pilling, S., Richards, D., … Yule, W. (2010). Do all psychological treatments really work the same in posttraumatic stress disorder? Clinical Psychology Review, 30(2), 269–276.  https://doi.org/10.1016/j.cpr.2009.12.001 CrossRefPubMedPubMedCentralGoogle Scholar
  20. Ehring, T., Ehlers, A., & Glucksman, E. (2008). Do cognitive models help in predicting the severity of posttraumatic stress disorder, phobia, and depression after motor vehicle accidents? A prospective longitudinal study. Journal of Consulting and Clinical Psychology, 76(2), 219–230.  https://doi.org/10.1037/0022-006X.76.2.219 CrossRefPubMedPubMedCentralGoogle Scholar
  21. 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 CrossRefPubMedPubMedCentralGoogle Scholar
  22. Fazel, M., Reed, R. V., Panter-Brick, C., & Stein, A. (2012). Mental health of displaced and refugee children resettled in high-income countries: Risk and protective factors. The Lancet, 379(9812), 266–282.  https://doi.org/10.1016/S0140-6736(11)60051-2 CrossRefGoogle Scholar
  23. Fazel, M., Wheeler, J., & Danesh, J. (2005). Prevalence of serious mental disorder in 7000 refugees resettled in western countries: A systematic review. The Lancet, 365(9467), 1309–1314.  https://doi.org/10.1016/S0140-6736(05)61027-6 CrossRefGoogle Scholar
  24. Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99(1), 20–35.CrossRefGoogle Scholar
  25. Gilbert, P. (2006). Evolution and depression: Issues and implications. Psychological Medicine, 36(3), 287–297.  https://doi.org/10.1017/S0033291705006112 CrossRefPubMedGoogle Scholar
  26. Halligan, S. L., Michael, T., Clark, D. M., & Ehlers, A. (2003). Posttraumatic stress disorder following assault: The role of cognitive processing, trauma memory, and appraisals. Journal of Consulting and Clinical Psychology, 71(3), 419–431.  https://doi.org/10.1037/0022-006x.71.3.419 CrossRefGoogle Scholar
  27. Hensel-Dittmann, D., Schauer, M., Ruf, M., Catani, C., Odenwald, M., Elbert, T., & Neuner, F. (2011). Treatment of traumatized victims of war and torture: A randomized controlled comparison of narrative exposure therapy and stress inoculation training. Psychotherapy and Psychosomatics, 80(6), 345–352.  https://doi.org/10.1159/000327253 CrossRefPubMedGoogle Scholar
  28. Hijazi, A. M. (2012). Narrative Exposure Therapy to treat traumatic stress in Middle Eastern refugees: A clinical trial (Doctoral dissertation). Retrieved from ProQuest Dissertations and Theses database. (Order No. 3527991).Google Scholar
  29. Hijazi, A. M., Lumley, M. A., Ziadni, M. S., Haddad, L., Rapport, L. J., & Arnetz, B. B. (2014). Brief narrative exposure therapy for posttraumatic stress in Iraqi refugees: A preliminary randomized clinical trial. Journal of Traumatic Stress, 27(3), 314–322.  https://doi.org/10.1002/jts.21922 CrossRefPubMedPubMedCentralGoogle Scholar
  30. Hofer, M. A. (2006). Psychobiological roots of early attachment. Current Directions in Psychological Science, 15(2), 84–88.  https://doi.org/10.1111/j.0963-7214.2006.00412.x CrossRefGoogle Scholar
  31. Jacob, N., Neuner, F., Maedl, A., Schaal, S., & Elbert, T. (2014). Dissemination of psychotherapy for trauma spectrum disorders in postconflict settings: A randomized controlled trial in Rwanda. Psychotherapy and Psychosomatics, 83(6), 354–363.  https://doi.org/10.1159/000365114 CrossRefPubMedGoogle Scholar
  32. Jelinek, L., Randjbar, S., Seifert, D., Kellner, M., & Moritz, S. (2009). The organization of autobiographical and nonautobiographical memory in posttraumatic stress disorder (PTSD). Journal of Abnormal Psychology, 118(2), 288–298.  https://doi.org/10.1037/a0015633 CrossRefPubMedGoogle Scholar
  33. Jordans, M. J., & Tol, W. A. (2012). Mental health in humanitarian settings: Shifting focus to care systems. International Health, 5(1), 9–10.CrossRefPubMedPubMedCentralGoogle Scholar
  34. Karunakara, U. K., Neuner, F., Schauer, M., Singh, K., Hill, K., Elbert, T., & Burnha, G. (2004). Traumatic events and symptoms of post-traumatic stress disorder amongst Sudanese nationals, refugees and Ugandans in the west Nile. African Health Sciences, 4(2), 83–93.PubMedPubMedCentralGoogle Scholar
  35. Kindt, M. (2014). A behavioural neuroscience perspective on the aetiology and treatment of anxiety disorders. Behaviour Research and Therapy, 62, 24–36.  https://doi.org/10.1016/j.brat.2014.08.012 CrossRefPubMedPubMedCentralGoogle Scholar
  36. Köbach, A., Schaal, S., Hecker, T., & Elbert, T. (2015). Psychotherapeutic intervention in the demobilization process: Addressing combat-related mental injuries with narrative exposure in a first and second dissemination stage. Clinical Psychology and Psychotherapy, 24, 807–825.CrossRefPubMedPubMedCentralGoogle Scholar
  37. Lang, P. J., Davis, M., & Ohman, A. (2000). Fear and anxiety: Animal models and human cognitive psychophysiology. Journal of Affective Disorders, 61(3), 137–159.CrossRefPubMedPubMedCentralGoogle Scholar
  38. Macdonald, G., & Leary, M. R. (2005). Why does social exclusion hurt? The relationship between social and physical pain. Psychological Bulletin, 131(2), 202–223.  https://doi.org/10.1037/0033-2909.131.2.202 CrossRefPubMedPubMedCentralGoogle Scholar
  39. Marx, B. P., Forsyth, J. P., Gallup, G. G., & Fusé, T. (2008). Tonic immobility as an evolved predator defense: Implications for sexual assault survivors. Clinical Psychology: Science and Practice, 15(1), 74–90.  https://doi.org/10.1111/j.1468-2850.2008.00112.x CrossRefGoogle Scholar
  40. McPherson, J. (2011). Does Narrative Exposure Therapy reduce PTSD in survivors of mass violence? Research on Social Work Practice, 22(1), 29–42.  https://doi.org/10.1177/1049731511414147 CrossRefGoogle Scholar
  41. Meerlo, P., Overkamp, G. J., Daan, S., van den Hoofdakker, R. H., & Koolhaas, J. M. (1996). Changes in behaviour and body weight following a single or double social defeat in rats. Stress, 1(1), 21–32.CrossRefPubMedGoogle Scholar
  42. Meerlo, P., Sgoifo, A., de Boer, S. F., & Koolhaas, J. M. (1999). Long-lasting consequences of a social conflict in rats: Behavior during the interaction predicts subsequent changes in daily rhythms of heart rate, temperature, and activity. Behavioral Neuroscience, 113(6), 1283–1290.CrossRefPubMedGoogle Scholar
  43. Metcalfe, J., & Jacobs, W. J. (1996). A “hot-system/cool-system” view of memory under stress. PTSD Research Quarterly, 7(2), 1–3.Google Scholar
  44. Mineka, S., & Suomi, S. J. (1978). Social separation in monkeys. Psychological Bulletin, 85(6), 1376–1400.  https://doi.org/10.1037/0033-2909.85.6.1376 CrossRefPubMedGoogle Scholar
  45. Miller, G., Elbert, T., & Rockstroh, B. (2005). Judging psychiatric disorders in refugees. The Lancet, 366(9497), 1604–1605.CrossRefGoogle Scholar
  46. Morath, J., Gola, H., Sommershof, A., Hamuni, G., Kolassa, S., Catani, C., … Elbert, T. (2014). The effect of trauma-focused therapy on the altered T cell distribution in individuals with PTSD: Evidence from a randomized controlled trial. Journal of Psychiatric Research, 54, 1–10.  https://doi.org/10.1016/j.jpsychires.2014.03.016 CrossRefPubMedGoogle Scholar
  47. Morath, J., Moreno-Villanueva, M., Hamuni, G., Kolassa, S., Ruf-Leuschner, M., Schauer, M., … Kolassa, I. -T. (2014). Effects of psychotherapy on DNA strand break accumulation originating from traumatic stress. Psychotherapy and Psychosomatics, 83(5), 289–297.CrossRefPubMedGoogle Scholar
  48. Nandi, C., Crombach, A., Bambonyé, M., Elbert, T., & Weierstall, R. (2015). Predictors of post-traumatic stress and appetitive aggression in active soldiers and former combatants. European Journal of Psychotraumatology, 6(1), 26553.  https://doi.org/10.3402/ejpt.v6.26553 CrossRefPubMedGoogle Scholar
  49. 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 CrossRefPubMedGoogle Scholar
  50. 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 CrossRefGoogle Scholar
  51. Neuner, F., Schauer, M., Karunakara, U., Klaschik, C., Robert, C., & Elbert, T. (2004). Psychological trauma and evidence for enhanced vulnerability for posttraumatic stress disorder through previous trauma among West Nile refugees. BMC Psychiatry, 4(1), 34.  https://doi.org/10.1186/1471-244X-4-34 CrossRefPubMedPubMedCentralGoogle Scholar
  52. Olema, D. K., Catani, C., Ertl, V., Saile, R., & Neuner, F. (2014). The hidden effects of child maltreatment in a war region: Correlates of psychopathology in two generations living in Northern Uganda. Journal of Traumatic Stress, 27(1), 35–41.  https://doi.org/10.1002/jts.21892 CrossRefPubMedGoogle Scholar
  53. Pessoa, L., & Adolphs, R. (2010). Emotion processing and the amygdala: From a ‘low road’ to ‘many roads’ of evaluating biological significance. Nature Reviews Neuroscience, 11(11), 773–783.  https://doi.org/10.1038/nrn2920 CrossRefPubMedPubMedCentralGoogle Scholar
  54. Price, J., Sloman, L., Gardner, R., Gilbert, P., & Rohde, P. (1994). The social competition hypothesis of depression. The British Journal of Psychiatry, 164(3), 309–315.  https://doi.org/10.1192/bjp.164.3.309 CrossRefPubMedGoogle Scholar
  55. Robjant, K., & Fazel, M. (2010). The emerging evidence for Narrative Exposure Therapy: A review. Clinical Psychology Review, 30(8), 1030–1039.  https://doi.org/10.1016/j.cpr.2010.07.004 CrossRefGoogle Scholar
  56. Saile, R., Ertl, V., Neuner, F., & Catani, C. (2016). Children of the postwar years: A two-generational multilevel risk assessment of child psychopathology in Northern Uganda. Development and Psychopathology, 28(2), 607–620.  https://doi.org/10.1017/S0954579415001066 CrossRefPubMedGoogle Scholar
  57. Saile, R., Neuner, F., Ertl, V., & Catani, C. (2013). Prevalence and predictors of partner violence against women in the aftermath of war: A survey among couples in Northern Uganda. Social Science & Medicine, 86, 17–25.  https://doi.org/10.1016/j.socscimed.2013.02.046 CrossRefGoogle Scholar
  58. Schauer, M., & Elbert, T. (2010). Dissociation following traumatic stress: Etiology and treatment. Zeitschrift Für Psychologie/Journal of Psychology, 218(2), 109–127.  https://doi.org/10.1027/0044-3409/a000018 CrossRefGoogle Scholar
  59. Schauer, M., Elbert, T., Gotthardt, S., Rockstroh, B., Odenwald, M., & Neuner, F. (2006). Wiedererfahrung durch Psychotherapie modifiziert Geist und Gehirn. Verhaltenstherapie, 16(2), 96–103.  https://doi.org/10.1159/000093195 CrossRefGoogle Scholar
  60. Schauer, M., Neuner, F., & Elbert, T. (2011). Narrative Exposure Therapy: A short-term treatment for traumatic stress disorders (2nd ed.). Cambridge, MA: Hogrefe Publishing.Google Scholar
  61. Schauer, M., & Schauer, E. (2010). Trauma-focused public mental-health interventions: A paradigm shift in humanitarian assistance and aid work. In E. Martz (Ed.), Trauma rehabilitation after war and conflict (pp. 361–430). New York, NY: Springer Publishing.Google Scholar
  62. Schnyder, U., Bryant, R. A., Ehlers, A., Foa, E. B., Hasam, A., Mwiti, G., … Yule, W. (2016). Culture-sensitive psychotraumatology. European Journal of Psychotraumatology, 7(1), 31179.CrossRefGoogle Scholar
  63. Silove, D., Steel, Z., & Watters, C. (2000). Policies of deterrence and the mental health of asylum seekers. JAMA, 284(5), 604–611.CrossRefGoogle Scholar
  64. Steel, Z., Chey, T., Silove, D., Marnane, C., Bryant, R. A., & van Ommeren, M. (2009). Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: A systematic review and meta-analysis. JAMA, 302(5), 537–549.  https://doi.org/10.1001/jama.2009.1132 CrossRefPubMedPubMedCentralGoogle Scholar
  65. 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 CrossRefPubMedGoogle Scholar
  66. Taylor, P. J., Gooding, P., Wood, A. M., & Tarrier, N. (2011). The role of defeat and entrapment in depression, anxiety, and suicide. Psychological Bulletin, 137(3), 391–420.  https://doi.org/10.1037/a0022935 CrossRefPubMedGoogle Scholar
  67. ter Heide, F. J. J., Mooren, T. M., & Kleber, R. J. (2016). Complex PTSD and phased treatment in refugees: A debate piece. European Journal of Psychotraumatology, 7(1), 28687.  https://doi.org/10.3402/ejt.v7.28687 CrossRefPubMedGoogle Scholar
  68. Williams, K. D. (2007). Ostracism. Annual Review of Psychology, 58, 425–452.  https://doi.org/10.1146/annurev.psych.58.110405.085641 CrossRefPubMedGoogle Scholar
  69. 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(1), 41.  https://doi.org/10.1186/1471-244X-13-41 CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  1. 1.Clinical PsychologyBielefeld UniversityBielefeldGermany
  2. 2.Clinical Psychology and NeuropsychologyUniversity of KonstanzKonstanzGermany
  3. 3.Centre of Excellence for PsychotraumatologyUniversity of KonstanzKonstanzGermany

Personalised recommendations